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      Relationship of Self-Rated Health with Fatal and Non-Fatal Outcomes in Cardiovascular Disease: A Systematic Review and Meta-Analysis

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          People who rate their health as poor experience higher all-cause mortality. Study of disease-specific association with self-rated health might increase understanding of why this association exists.


          To estimate the strength of association between self-rated health and fatal and non-fatal cardiovascular disease.


          A comprehensive search of PubMed MEDLINE, EMBASE, CINAHL, BIOSIS, PsycINFO, DARE, Cochrane Library, and Web of Science was undertaken during June 2013. Two reviewers independently searched databases and selected studies. Inclusion criteria were prospective cohort studies or cohort analyses of randomised trials with baseline measurement of self-rated health with fatal or non-fatal cardiovascular outcomes. 20 studies were pooled quantitatively in different meta-analyses. Study quality was assessed using Newcastle-Ottawa scales.


          ‘Poor’ relative to ‘excellent’ self-rated health (defined by most extreme categories in each study, most often’ poor’ or ‘very poor’ and ‘excellent’ or ‘good’) was associated over a follow-up of 2.3–23 years with cardiovascular mortality in studies: where varying degrees of adjustments had been made for cardiovascular disease risk (HR 1.79 (95% CI 1.50 to 2.14); 15 studies, I2 = 71.24%), and in studies reporting outcomes in people with pre-existing cardiovascular disease or ischaemic heart disease symptoms (HR 2.42 (95% CI 1.32 to 4.44); 3 studies; I2 = 71.83%). ‘Poor’ relative to ‘excellent’ self rated health was also associated with the combined outcome of fatal and non-fatal cardiovascular events (HR 1.90 (95% CI 1.26 to 2.87); 5 studies; I 2 = 68.61%), Self-rated health was not significantly associated with non-fatal cardiovascular disease outcomes (HR 1.66 (95% CI 0.96 to 2.87); 5 studies; I2 = 83.60%).


          Poor self rated health is associated with cardiovascular mortality in populations with and without prior cardiovascular disease. Those with current poor self-rated health may warrant additional input from health services to identify and address reasons for their low subjective health.

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          Most cited references 35

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          Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

          David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
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            Operating characteristics of a rank correlation test for publication bias.

            An adjusted rank correlation test is proposed as a technique for identifying publication bias in a meta-analysis, and its operating characteristics are evaluated via simulations. The test statistic is a direct statistical analogue of the popular "funnel-graph." The number of component studies in the meta-analysis, the nature of the selection mechanism, the range of variances of the effect size estimates, and the true underlying effect size are all observed to be influential in determining the power of the test. The test is fairly powerful for large meta-analyses with 75 component studies, but has only moderate power for meta-analyses with 25 component studies. However, in many of the configurations in which there is low power, there is also relatively little bias in the summary effect size estimate. Nonetheless, the test must be interpreted with caution in small meta-analyses. In particular, bias cannot be ruled out if the test is not significant. The proposed technique has potential utility as an exploratory tool for meta-analysts, as a formal procedure to complement the funnel-graph.
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              The benefits of frequent positive affect: does happiness lead to success?

              Numerous studies show that happy individuals are successful across multiple life domains, including marriage, friendship, income, work performance, and health. The authors suggest a conceptual model to account for these findings, arguing that the happiness-success link exists not only because success makes people happy, but also because positive affect engenders success. Three classes of evidence--crosssectional, longitudinal, and experimental--are documented to test their model. Relevant studies are described and their effect sizes combined meta-analytically. The results reveal that happiness is associated with and precedes numerous successful outcomes, as well as behaviors paralleling success. Furthermore, the evidence suggests that positive affect--the hallmark of well-being--may be the cause of many of the desirable characteristics, resources, and successes correlated with happiness. Limitations, empirical issues, and important future research questions are discussed.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                30 July 2014
                : 9
                : 7
                [1 ]Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Cambridge, United Kingdom
                [2 ]Primary Care Unit, Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
                Innsbruck Medical University, Austria
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: NM RP SS ALK JM. Performed the experiments: NM SS RP. Analyzed the data: NM SS RP. Contributed reagents/materials/analysis tools: RP. Contributed to the writing of the manuscript: NM RP SS ALK JM.


                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 13
                This report presents independent commissioned research by the National Institute for Health Research (NIHR) through the National School for Primary Care Research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. NM was funded through an NIHR Walport Clinical Lectureship.
                Research Article
                Medicine and Health Sciences
                Cardiovascular Diseases
                Cardiovascular Disease Risk
                Public and Occupational Health
                Behavioral and Social Aspects of Health
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                The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Information files.



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