Cancer incidence and mortality projections up to 2020 in Catalonia by means of Bayesian models

PURPOSE: To predict the burden of cancer in Catalonia by 2020 assessing changes in demography and cancer risk during 2010-2020. ETHODS/PATIENTS: Data were obtained from Tarragona and Girona cancer registries and Catalan mortality registry. Population age distribution was obtained from the Catalan Institute of Statistics. Predicted cases in Catalonia were estimated through autoregressive Bayesian age-period-cohort models. RESULTS: There will be diagnosed 26,455 incident cases among men and 18,345 among women during 2020, which means an increase of 22.5 and 24.5 % comparing with the cancer incidence figures of 2010. In men, the increase of cases (22.5 %) can be partitioned in three components: 12 % due to ageing, 8 % due to increase in population size and 2 % due to cancer risk. In women, the role of each component was 9, 8 and 8 %, respectively. The increased risk is mainly expected to be observed in tobacco-related tumours among women and in colorectal and liver cancers among men. During 2010-2020 a mortality decline is expected in both sexes. CONCLUSION: The expected increase of cancer incidence, mainly due to tobacco-related tumours in women and colorectal in men, reinforces the need to strengthen smoking prevention and the expansion of early detection of colorectal cancer in Catalonia (AU)

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Time trends of cancer incidence and mortality in Catalonia during 1993-2007

PURPOSE: To describe time trends of cancer in Catalonia, Spain, during the period 1993-2007. METHODS/PATIENTS: Data have been provided by two population-based cancer registries, Girona and Tarragona, and the Catalan mortality registry. Cancer incidence in Catalonia has been estimated through modeling methods using data from these health structures. RESULTS: During 2003-2007, there were 20,042 cancer cases and 9,842 deaths per year among men and 13,673 new cancer cases and 5,882 deaths among women. The most frequent incident cancers among men were prostate (N = 4,258), lung (N = 3,021), colorectal (N = 3,007) and bladder (N = 2,238), whereas among women they were breast (N = 3,907), colorectal (N = 2,088), corpus uteri (N = 734) and lung (N = 527). During 1993-2007, age-standardized incidence rates (ASIRs) rose 1.2 % per year among men [prostate (6.3 %), testis (5.7 %), kidney (2.9 %), liver (2.2 %) and colorectal (2.1 %)]. ASIRs decreased for stomach (-2.9 %), oral cavity and pharynx (-2.8 %), larynx (-2.7 %) and esophagus (-2 %). Among women, ASIRs only rose for lung (5.2 %), kidney (3.1 %), oral cavity and pharynx (2.6 %) and thyroid (1.6 %). ASIRs decreased for corpus uteri (-2.3 %), stomach (-1.7 %) and ovary (-1.6 %). Cancer mortality decreased -1.3 % per year among men and -2.1 % among women during the same period. CONCLUSION: Among men, the decrease of incidence/mortality of tobacco-related tumors was related to a reduction of smoking prevalence. Among women, the stabilization of breast cancer incidence and the rise of lung cancer incidence are similar to that observed in most European regions. These results allow assessing the effectiveness of public health strategies and they pose new frontiers for cancer control in Catalonia (AU)

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Time trends of cancer incidence and mortality in Catalonia during 1993-2007.

PURPOSE: To describe time trends of cancer in Catalonia, Spain, during the period 1993-2007. METHODS/PATIENTS: Data have been provided by two population-based cancer registries, Girona and Tarragona, and the Catalan mortality registry. Cancer incidence in Catalonia has been estimated through modeling methods using data from these health structures. RESULTS: During 2003-2007, there were 20,042 cancer cases and 9,842 deaths per year among men and 13,673 new cancer cases and 5,882 deaths among women. The most frequent incident cancers among men were prostate (N = 4,258), lung (N = 3,021), colorectal (N = 3,007) and bladder (N = 2,238), whereas among women they were breast (N = 3,907), colorectal (N = 2,088), corpus uteri (N = 734) and lung (N = 527). During 1993-2007, age-standardized incidence rates (ASIRs) rose 1.2 % per year among men [prostate (6.3 %), testis (5.7 %), kidney (2.9 %), liver (2.2 %) and colorectal (2.1 %)]. ASIRs decreased for stomach (-2.9 %), oral cavity and pharynx (-2.8 %), larynx (-2.7 %) and esophagus (-2 %). Among women, ASIRs only rose for lung (5.2 %), kidney (3.1 %), oral cavity and pharynx (2.6 %) and thyroid (1.6 %). ASIRs decreased for corpus uteri (-2.3 %), stomach (-1.7 %) and ovary (-1.6 %). Cancer mortality decreased -1.3 % per year among men and -2.1 % among women during the same period. CONCLUSION: Among men, the decrease of incidence/mortality of tobacco-related tumors was related to a reduction of smoking prevalence. Among women, the stabilization of breast cancer incidence and the rise of lung cancer incidence are similar to that observed in most European regions. These results allow assessing the effectiveness of public health strategies and they pose new frontiers for cancer control in Catalonia.

Cancer incidence and mortality projections up to 2020 in Catalonia by means of Bayesian models.

PURPOSE: To predict the burden of cancer in Catalonia by 2020 assessing changes in demography and cancer risk during 2010-2020. METHODS/PATIENTS: Data were obtained from Tarragona and Girona cancer registries and Catalan mortality registry. Population age distribution was obtained from the Catalan Institute of Statistics. Predicted cases in Catalonia were estimated through autoregressive Bayesian age-period-cohort models. RESULTS: There will be diagnosed 26,455 incident cases among men and 18,345 among women during 2020, which means an increase of 22.5 and 24.5 % comparing with the cancer incidence figures of 2010. In men, the increase of cases (22.5 %) can be partitioned in three components: 12 % due to ageing, 8 % due to increase in population size and 2 % due to cancer risk. In women, the role of each component was 9, 8 and 8 %, respectively. The increased risk is mainly expected to be observed in tobacco-related tumours among women and in colorectal and liver cancers among men. During 2010-2020 a mortality decline is expected in both sexes. CONCLUSION: The expected increase of cancer incidence, mainly due to tobacco-related tumours in women and colorectal in men, reinforces the need to strengthen smoking prevention and the expansion of early detection of colorectal cancer in Catalonia.

Type 1 diabetes and perinatal factors in Catalonia (Spain).

AIM: To identify perinatal risk factors associated with the development of type 1 diabetes. METHODS: The research was designed as a retrospective study of cases and controls. Catalan Register of Diabetes and the Register of Newborn Screening for Metabolic Diseases were the data sources used in this study. The variables studied include sex, birth weight, age of onset of type 1 diabetes, maternal age at delivery, type of delivery, and type of feeding at birth. Anthropometric growth patterns of Carrascosa have been used to classify birth weight as small for gestational age: weight <10th percentile; appropriate for gestational age: weight ≥10th percentile and ≤90th percentile; and large for gestational age (LGA): weight >90th percentile. Statistical analysis was carried out using bivariate analysis (chi-squared test), and odds ratios and 95% confidence intervals were predicted. RESULTS: A total of 1530 infants were analyzed (306 type 1 diabetes cases, 1224 control subjects). A significantly greater percentage of LGA babies were observed among diabetics (16.3% compared with 11.3% of the control group). The risk of having type 1 diabetes in children who were LGA was 1.45 times greater than that shown in children with normal and low birth weight. CONCLUSIONS: Only being born LGA was significantly associated with developing type 1 diabetes.

Rising trends in incidence of cutaneous malignant melanoma and their future projections in Catalonia, Spain: increasing impact or future epidemic?

BACKGROUND: During the past decades, there has been a substantial increase in the incidence of cutaneous malignant melanoma (CMM) among all Caucasian populations. Spain presents one of Europe's lowest incidence and mortality rates. OBJECTIVE: The aim of this study was to analyse the recent trends of CMM incidence and mortality in a region with lower incidence as well as to project their future trends. METHODS: Cutaneous malignant melanoma incidence data were provided by the Tarragona and Girona population-based cancer registries and mortality data were provided by the Mortality Registry of Catalonia. Time trends of incidence and mortality rates by CMM were assessed through the estimated annual percentages of change of the incidence and mortality age-standardized rates to the World Standard Population. Projections were based on a Bayesian age-period-cohort model using second order autoregressive effects on age. RESULTS: During the last 20 years CMM incidence has increased substantially at a faster rate than any other neoplasms in Catalonia, particularly among women and this trend will probably continue for the next several years. Nevertheless, CMM mortality trends have been and probably will remain stable during this period. CONCLUSION: Improvements in preventive activities should be implemented to decrease incidence and mortality from this cancer. Monitoring stage-specific trends in CMM incidence can assess the impact of preventive strategies; for this reason more complete information on diagnostic features of CMM patients in the Spanish population-based cancer registries are necessary.

Life expectancy and age-period-cohort effects: analysis and projections of mortality in Spain between 1977 and 2016.

OBJECTIVES: This study aimed to: (1) assess Spanish mortality trends between 1977 and 2001 and their impact on life expectancy; and (2) assess the differences in life expectancy between men and women for the period 2002-2016. STUDY DESIGN: Time trends study using age-period-cohort (APC) analysis. METHODS: A Bayesian APC model was fitted to describe Spanish mortality rates for the period 1977-2001 and to project Spanish mortality rates for 2002-2016. Life expectancy was predicted through Chiang's method using projected mortality rates. RESULTS: There was a significant cohort effect for Spanish mortality, showing a slight increase in mortality among men aged 20-39 years between 1986 and 1997 (birth cohorts 1940-1970). Life expectancy is expected to increase by approximately 0.5% in men and women between 1977 and 2016 (1 year per 5-year period). Life expectancy for males born between 2012 and 2016 will be 77.15 years, compared with 84.95 years for females born during the same period. CONCLUSIONS: The rising trend in mortality among the 1940-1970 cohorts may be due to the increased risk of avoidable causes of death related to acquired immunodeficiency syndrome, traffic accidents, and drug and alcohol abuse during the mid 1980s. The decline in mortality rates in recent years could lead to a mean increase in life expectancy of 1 year per 5-year period in both genders between 2002 and 2016. An increase in life expectancy for women and a levelling off for men is expected for age groups older than 79 years.

[Cancer mortality trends in Catalonia, 1985-2004]. / Tendencias de la mortalidad por cáncer en Cataluña, 1985-2004.

BACKGROUND AND OBJECTIVE: In the last two decades, major changes have occurred in both the epidemiology and the healthcare of cancer, which have had a substantial impact on the mortality due to this disease. The objective of this study was to analyze cancer mortality trends in Catalonia in the previous 20 years and to compare these trends with those in Europe. SUBJECTS AND METHODS: Mortality data were gathered from the mortality register of the Department of Health of Catalonia, which includes all deaths in Catalonia from 1985-2004. The causes of death are coded according to the International Classification of Diseases (ICD-9 for 1985-1998 and ICD-10 for 1999-2004). The population data used were inter-census (1985-2000), census (2001) and post-census (2002-2004) estimates from the Catalan Institute of Statistics. Ageadjusted rates (AR) (to the world population of 1960) and accumulated rates from 0 to 74 years old were calculated. A Poisson model was adjusted to the AR to estimate the mortality trend and the annual percentage of change was calculated for the years 1985-1994 and 1995- 2004 and for the period 1985-2002 as a whole. RESULTS: From 1985-2004, the risk of dying from cancer decreased from 18.54 % to 17.49% in men and from 9.24% to 7.69% in women. The adjusted rate of mortality decreased in cancer of the larynx (2,52%), prostate (1.11%) and stomach (2.89%) in men and in stomach cancer (-3.64) in women. In men, there was a significant increase in mortality from colorectal cancer (an increase of 2.8% to 1994 with subsequent stabilization) and from lung cancer (an increase of 1.36% to 1994 with a subsequent decrease). Cancer of the liver showed a nonsignificant increase until 1994 with a subsequent decrease of 3.13%. In women, breast cancer increased until 1994 (1.48%) and subsequently significantly decreased (2.72%). Lung cancer increased throughout the entire period but this increase was only significant (4,81%) in the last decade. CONCLUSIONS: In the last two decades, cancer mortality has shown a general decreasing trend, although mortality from several tumors has substantially increased. Compared with other European countries, Catalonia shows lower cancer mortality in women than in men. Nevertheless, the trends shown in the last decade are similar to those followed by the countries in the best positions.

[Predictions of cancer incidence and mortality in Catalonia to 2015 by means of Bayesian models]. / Proyección de la incidencia y la mortalidad del cáncer en Cataluña hasta el año 2015 mediante un modelo bayesiano.

BACKGROUND AND OBJECTIVE: To perform cancer incidence and mortality projections in Catalonia for the period 2005-2019. To assess the projected increase in the incidence in 2015 compared with that in 2005, and to determine whether this increase is attributable to changes in risk or in demographics. POPULATION AND METHOD: Bayesian age-period-cohort models were fitted to age-specific rates for 1985-2004 to obtain the expected number of cases for the 5-year periods 2005-2009, 2010-2014 and 2015- 2019. Annual cases were estimated through a polynomial interpolation model. Incidence and mortality data were obtained from the Tarrragona and Gerona cancer registries, while population pyramids for the period 1985-2019 were obtained from the Catalan Institute of Statistics. RESULTS: In Catalonia, 27,438 cancer cases will be diagnosed among men and 19,986 among women in 2015, representing an increase in the number of cases diagnosed of 31% and 34%, respectively, when compared with those diagnosed in 2005 (20,999 and 14,141, respectively). In men, the increases attributable to risk, aging and demographic changes are 10%, 14% and 7%, respectively, whereas in women these changes are 6%, 13% and 15%. In the next decade, cancer mortality is expected to stabilize in men and to continue to decrease in women. Major increases in cancer incidence and mortality are expected among old age groups. CONCLUSIONS: The present study highlights the need to reorganize the resources and infrastructures required for cancer control and care, taking into account the predicted burden of oncology patients.

Proyección de la incidencia y la mortalidad del cáncer en Cataluña hasta el año 2015 mediante un modelo bayesiano / Predictions of cancer incidence and mortality in Catalonia to 2015 by means of Bayesian models

FUNDAMENTOS Y OBJETIVOS: Proyectar la incidencia y la mortalidad por cáncer en Cataluña en el período 2005-2019. Analizar el incremento pronosticado de la incidencia en 2015 respecto a la del año 2005 y determinar si es debida a cambios en el riesgo o a componentes demográficos. POBLACIÓN Y MÉTODO: Mediante modelos edad-período-cohorte bayesianos se han ajustado para Cataluña las tasas brutas de incidencia y mortalidad por cáncer en el período 1985-2004 y el número de casos esperados en los quinquenios 2005-2009, 2010-2014 y 2015-2019. Los casos anuales se calcularon mediante una interpolación polinómica. La incidencia y la mortalidad por cáncer se obtuvieron de los registros de cáncer de Girona y Tarragona y del Registro de mortalidad de Cataluña; las pirámides poblacionales del período 1985-2019, del Instituto de Estadística de Cataluña. RESULTADOS: En 2015 se diagnosticarán 27.438 casos de cáncer en los varones y 19.986 en las mujeres, con lo que se producirá un incremento del 31% y el 34% respecto a los del año 2005 (20.999 y 14.141, respectivamente). En los varones, el aumento esperado de casos de cáncer debido a cambios en el riesgo, el envejecimiento y en el tamaño poblacional son respectivamente del 10, el 14 y el 7% y, en las mujeres, del 6, el 13 y el 15%. En los varones se augura una estabilización de la mortalidad por cáncer en los próximos años, mientras que se espera que siga disminuyendo en las mujeres. Los incrementos de la incidencia y la mortalidad serán más importantes en los individuos de edad avanzada. CONCLUSIONES: El presente estudio remarca la necesidad de reorganizar los recursos y las infraestructuras necesarias en el control y la asistencia del cáncer en Cataluña, a fin de anticiparse al incremento de pacientes oncológicos

BACKGROUND AND OBJECTIVE: To perform cancer incidence and mortality projections in Catalonia for the period 2005-2019. To assess the projected increase in the incidence in 2015 compared with that in 2005,and to determine whether this increase is attributable to changes in risk or in demographics. POPULATION AND METHOD: Bayesian age-period-cohort models were fitted to age-specific rates for 1985-2004 to obtain the expected number of cases for the 5-year periods 2005-2009, 2010-2014 and 2015- 2019. Annual cases were estimated through a polynomial interpolation model. Incidence and mortality data were obtained from the Tarrragona and Gerona cancer registries, while population pyramids for the period 1985-2019 were obtained from the Catalan Institute of Statistics. RESULTS: In Catalonia, 27,438 cancer cases will be diagnosed among men and 19,986 among women in 2015, representing an increase in the number of cases diagnosed of 31% and 34%, respectively, when compared with those diagnosed in 2005 (20,999 and 14,141, respectively). In men, the increases attributable to risk, aging and demographic changes are 10%, 14% and 7%, respectively, whereas in women these changes are 6%, 13% and 15%. In the next decade, cancer mortality is expected to stabilize in men and to continue to decrease in women. Major increases in cancer incidence and mortality are expected among old age groups. CONCLUSIONS: The present study highlights the need to reorganize the resources and infrastructures required for cancer control and care, taking into account the predicted burden of oncology patients

Análisis de la incidencia, la supervivencia y la mortalidad según las principales localizaciones tumorales, 1985-2019: cáncer de mama / No disponible

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Análisis de la incidencia, la supervivencia y la mortalidad según las principales localizaciones tumorales, 1985-2019: cáncer de estómago / No disponible

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Tendencias de la mortalidad por cáncer en Cataluña, 1985-2004 / Cancer mortality trends in Catalonia, 1985-2004

FUNDAMENTO Y OBJETIVO: Tanto la situación epidemiológica como asistencial del cáncer en las últimas 2 décadas ha experimentado grandes cambios y esto ha influido en la mortalidad por esta enfermedad. El objetivo es analizar las tendencias de la mortalidad por cáncer en Cataluña, durante los últimos 20 años y compararlas con Europa. SUJETOS Y MÉTODO: Los datos de las defunciones ocurridas en Cataluña proceden del registro de mortalidad del Departamento de Salud y están codificados según la Clasificación Internacional de Enfermedades (CIE) (novena revisión de 1985-1998 y décima de 1999 a 2004). La población corresponde a la intercensal (1985-2000), censal (2001) y poscensal (2002-2004) del Instituto de Estadística de Cataluña. Se han calculado las tasas ajustadas por edad (TA) mediante el método directo (población estándar mundial de 1960) y las tasas acumuladas (Tac) de 0 a 74 años. Para evaluar la tendencia se ha ajustado un modelo de Poisson a las TA y se ha estimado el porcentaje de cambio anual (PCA) para los decenios 1985-1994 y 1995-2004 y el global para 1985-2004. RESULTADOS: El riesgo de morir por cáncer (Tac) ha pasado en los varones del 18,54 al 17,49% y en las mujeres, del 9,24 al 7,69% de 1985 a 2002. En estos años ha disminuido la mortalidad (PCA) por los cánceres de laringe (¿2,52%), próstata (¿1,11%) y estómago (¿2,89%) en varones y estómago (¿3,64%) en mujeres. Mostraron cambios de tendencia en los varones el cáncer colorrectal (aumento del 2,8% hasta 1994 y estabilización posterior), pulmón (creció el 1,36% hasta 1994 y después descendió) e hígado (aumento no significativo hasta 1994 y luego descenso de ¿3,13%). En las mujeres la mortalidad por cáncer de mama primero aumentó (1,48%) y después disminuyó (¿2,72%) significativamente y el de pulmón aumentó en todo el período, aunque sólo en la última década (4,81%) fue estadísticamente significativo. CONCLUSIONES: La mortalidad por cáncer en las últimas 2 décadas ha mostrado una tendencia general decreciente, aunque algunas localizaciones aumentan. Comparada con otros países, Cataluña se encuentra en una situación más favorable en el caso de las mujeres que en el de los varones, aunque la evolución de los últimos años ha sido parecida a la de los países que se encuentran en situación más ventajosa

BACKGROUND AND OBJECTIVE: In the last two decades, major changes have occurred in both the epidemiology and the healthcare of cancer, which have had a substantial impact on the mortality due to this disease. The objective of this study was to analyze cancer mortality trends in Catalonia in the previous 20 years and to compare these trends with those in Europe. SUBJECTS AND METHODS: Mortality data were gathered from the mortality register of the Department of Health of Catalonia, which includes all deaths in Catalonia from 1985-2004. The causes of death are coded according to the International Classification of Diseases (ICD-9 for1985-1998 and ICD-10 for 1999-2004). The population data used were inter-census (1985-2000), census (2001) and post-census (2002-2004) estimates from the Catalan Institute of Statistics. Age adjusted rates (AR) (to the world population of 1960) and accumulated rates from 0 to 74 years old were calculated. A Poisson model was adjusted to the AR to estimate the mortality trend and the annual percentage of change was calculated for the years 1985-1994 and 1995- 2004 and for the period 1985-2002 as a whole. RESULTS: From 1985-2004, the risk of dying from cancer decreased from 18.54 % to 17.49% in men and from 9.24% to 7.69% in women. The adjusted rate of mortality decreased in cancer of the larynx (–2,52%), prostate (–1.11%) and stomach (–2.89%) in men and in stomach cancer (-3.64) in women. In men, there was a significant increase in mortality from colorectal cancer (an increase of 2.8% to 1994 with subsequent stabilization) and from lung cancer (an increase of 1.36% to 1994 with a subsequent decrease). Cancer of the liver showed a non-significant increase until 1994 with a subsequent decrease of –3.13%. In women, breast cancer increased until 1994 (1.48%) and subsequently significantly decreased (–2.72%). Lung cancer increased throughout the entire period but this increase was only significant (4,81%) in the last decade. CONCLUSIONS: In the last two decades, cancer mortality has shown a general decreasing trend, although mortality from several tumors has substantially increased. Compared with other European countries, Catalonia shows lower cancer mortality in women than in men. Nevertheless, the trends shown in the last decade are similar to those followed by the countries in the best positions

The impact of avoidable mortality on life expectancy at birth in Spain: changes between three periods, from 1987 to 2001.

OBJECTIVE: To evaluate the impact of avoidable mortality on the changes in life expectancy at birth in Spain. METHODS: Standard life table techniques and the Arriaga method were used to calculate and to decompose life expectancy (LE) changes by age, effects and groups of causes of avoidable mortality among three periods (1987-91, 1992-6 and 1997-2001). A list of causes of avoidable mortality reached by consensus and previously published in Spain was used. MAIN RESULTS: Life expectancy increased in all ages and both sexes. The main contribution to the increase of LE at birth was due to people over 50. Mortality in young adults produced a reduction in LE between the first two periods, but there was an important increase in LE between the last two periods; in both cases, this was the result of factors amenable to health policy interventions. The highest improvement in LE was due to non-avoidable causes, but avoidable mortality through health service interventions showed improvements in LE in those younger than 1 year and in those aged 45-75 years. CONCLUSIONS: Making a distinction between several groups of causes of avoidable mortality and using decomposition by causes, ages and effects allowed us to better explain the impact of avoidable mortality on the LE of the whole population and gave a new dimension to this indicator that could be very useful in public health.

Trends in childhood cancer incidence and mortality in Catalonia, Spain, 1975-1998.

Childhood cancer mortality has sharply declined in most economically developed countries over the last years, whereas no substantial changes in the incidence have been observed. In Catalonia (Spain), childhood cancer mortality showed a considerable decline until 1992, but incidence trends have not been analysed in this population. To assess both recent incidence and mortality trends in this population, we analysed childhood (0-14 years) cancer data from the population-based Tarragona Cancer Registry and from the Mortality Registry of Catalonia (Spain) from 1980 to 1998. All cancer mortality decreased by -2.6% annually in boys (95% confidence interval, 95% CI -3.7, -1.6) and -3.7% in girls (95% CI -4.9, -2.5). Mortality due to leukaemia decreased annually -3.0% in boys (95% CI -4.7, -1.4) and -4.4% in girls (95% CI -6.3, -2.4). Mortality for brain tumours showed a reduction of -3.2% in boys (95% CI -5.5, -0.9) and of -4.4% in girls (95% CI -6.3, -2.4). No significant trend in incidence rates, either in boys or in girls, was observed (annual per cent of change for all cancers -0.5%, 95% CI -3.5, 2.7, in boys and 1.7%, 95% CI -1.9, 5.5, in girls). These results suggest an improvement in both childhood cancer diagnosis and treatment, which may explain current higher childhood cancer survival rates.

Educational differences in health expectancy in Madrid and Barcelona.

Educational differences in Health Expectancy (HE) among residents older than 24 years of age in Madrid and Barcelona are evaluated. Death records were linked to the 1991 Population Census and self-perceived health from the National Health Interview Survey was used. Differences between the higher and the lower educational groups in HE at 25 years were: 7.5 years in men and 5.58 years in women in Madrid and 9.5 years in men and 13.4 years in women in Barcelona. Since HE combines mortality and health status, results presented may have important implications for health policy.