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Epidemiology Publish Ahead of Print DOI: 10.1097/EDE.0000000000000790 Manuscript title: Re. Effort–Reward Imbalance at Work and Incident Coronary Heart Disease

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Arturo Juárez García1, PhD; BongKyoo Choi2, ScD MPH; Paul Landsbergis3, PhD

Center for Transdisciplinary Research in Psychology, School of Psychology,

Universidad Autónoma del Estado de Morelos, Mexico. 2

Center for Occupational and Environmental Health, School of Medicine and Program

in Public Health, University of California, Irvine, USA. 3

State University of New York Downstate School of Public Health, New York, USA.

Corresponding author: Arturo Juárez García, PhD. , Center for Transdisciplinary

Research in Psychology, School of Psychology, Universidad Autónoma del Estado de Morelos, Mexico. Pico de Orizaba #1, Cuernavaca Morelos. CP 62350., E-mail:

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[email protected], Phone: 01777 3227970

Running head: Operationalization of effort-reward imbalance and coronary heart disease.

We declare no conflict of interest

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The manuscript did not receive any financial support. (368 words)

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Copyright © Wolters Kluwer Health, Inc. All rights reserved. Unauthorized reproduction of this article is prohibited.

Dear Editor: We recognize the important contribution of Dragano et al.’s study: “Effort–Reward Imbalance at Work and Incident Coronary Heart Disease: A Multicohort Study of 90,164 Individuals”1. At the same time, we think that the authors’ statement in the study: “The

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availability of alternative ways of defining effort–reward imbalance can encourage multiple testing and result in bias because of selective reporting” is misleading. Testing

alternative ways of defining effort-reward imbalance (ERI) does not result in a bias if all tests are reported. Rather, a bias can occur when researchers select just one method of

operationalization, while knowing previously that there are various ways. Dragano et al.

calculated the ERI score as the ratio of an effort scale divided by an reward scale indicating exposure group when values are higher than 1 (>1 criterion). Although this procedure has been the most traditional operationalization of ERI, other operationalizations of ERI exposure exist, but were not analyzed or discussed: 

defining the risk group as cases above median in both effort and low reward, as was

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done with job strain as a combination of low job control and high job demands in this study.

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using quartiles of the effort-reward ratio score, as we recommended before2, and as in a previous seminal paper about the short version of ERI questionnaire.3 an interaction term of effort and reward, as has been suggested by others4.

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We would like to know whether the association between ERI and coronary heart disease is consistent or not across several alternative operations of ERI in the study.

On the other hand, the authors made the very informative decision of testing the associations of ERI components, effort and reward (dichotomized at their medians) with

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CHD. Reward, but not effort, was significantly associated with CHD (1.18 HR). According to the original ERI model, reward is composed of three variables: income, respect and status. In order to better develop specific intervention and prevention strategies, we believe it would be even more informative to test the independent associations of the

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three types of rewards with CHD as well. We think it would be possible at least in the three cohorts (GAZEL, HNR, WOLF-F) of the IPD-Work Consortium where the original ERI

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questionnaire was used.

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Refernces 1.

Dragano N, Siegrist J, Nyberg ST, et al. Effort–Reward Imbalance at Work and Incident Coronary Heart Disease: A Multicohort Study of 90,164 Individuals. Epidemiology (Cambridge, Mass). 2017;28(4):619-626.

2.

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doi:10.1097/EDE.0000000000000666. Choi B, Schnall P, Landsbergis P, Dobson M, Ko S, Gómez-Ortiz V, Juárez-Garcia A, Baker D. Recommendations for individual participant data meta-analyses on

work stressors and health outcomes: comments on IPD-Work Consortium papers. Scand J Work Environ Health. 2015;41(3):299-311 3.

Siegrist J, N. Wege, F. Pu¨hlhofer, and M. Wahrendorf. . A short generic measure of work stress in the era of globalization: effort-reward imbalance. Int Arch Occup

Environ Health. 2009;82(8):1005–13. http://dx.doi.org/10.1007/s00420-008- 0384-3. 4.

Burr, Hermann, Maren Formazin, and Anne Pohrt. "Methodological and conceptual issues regarding occupational psychosocial coronary heart disease

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epidemiology." Scandinavian journal of work, environment & health 42.3 (2016):

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251-255.

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