The Cost-Effectiveness of Mandatory Folic Acid Fortification in Australia

• Published in: The Journal of nutrition Vol. 143; no. 1; pp. 59 - 66
• Main Authors: Rabovskaja, Viktoria, Parkinson, Bonny, Goodall, Stephen
• Format: Journal Article
• Language: English
• Published: Bethesda, MD Elsevier Inc 01.01.2013; American Society for Nutrition
• Subjects: Australia - epidemiology; Biological and medical sciences; Bread - adverse effects; Bread - analysis; Bread - economics; Cost-Benefit Analysis; DALY; Decision Trees; disability-adjusted life-year; Feeding. Feeding behavior; Folic Acid - administration & dosage; Folic Acid - adverse effects; Folic Acid - economics; Food Standards Australia New Zealand; Food, Fortified - adverse effects; Food, Fortified - economics; FSANZ; Fundamental and applied biological sciences. Psychology; Government Programs - economics; Health Promotion - economics; Health Utility Index; HUI; Humans; ICER; Incidence; incremental cost-effectiveness ratio; life-year gained; LYG; Mandatory Programs - economics; neural tube defect; Neural Tube Defects - economics; Neural Tube Defects - epidemiology; Neural Tube Defects - prevention & control; NTD; PBAC; Peripheral Nervous System Diseases - economics; Peripheral Nervous System Diseases - epidemiology; Peripheral Nervous System Diseases - etiology; Peripheral Nervous System Diseases - physiopathology; Pharmaceutical Benefits Advisory Committee; Prevalence; probabilistic sensitivity analysis; PSA; QALY; Quality-Adjusted Life Years; quality-adjusted life-year; Severity of Illness Index; Vertebrates: anatomy and physiology, studies on body, several organs or systems; Vitamin B 12 Deficiency - economics; Vitamin B 12 Deficiency - epidemiology; Vitamin B 12 Deficiency - physiopathology; Voluntary Programs - economics; willingness to pay; WTP; Australia; Oceania; FSANZ; PBAC; WTP; DALY; ICER; QALY; LYG; HUI; NTD; PSA; Micronutrient; Nutrition; Folic acid
• DOI: 10.3945/jn.112.166694
• ISSN: 0022-3166

The Australian government recently introduced mandatory folic acid fortification of bread to reduce the incidence of neural tube defects (NTDs). The economic evaluation of this policy contained a number of limitations. This study aimed to address the limitations and to reconsider the findings. Cost-effectiveness analysis was used to assess the cost and benefits of mandatory versus voluntary folic acid fortification. Outcomes measures were quality-adjusted life-years (QALYs), life-years gained (LYG), avoided NTD cases, and additional severe neuropathy cases. Costs considered included industry costs and regulatory costs to the government. It was estimated that mandatory fortification would prevent 31 NTDs, whereas an additional 14 cases of severe neuropathy would be incurred. Overall, 539 LYG and 503 QALYs would be gained per year of mandatory compared with voluntary fortification. Mandatory fortification was cost-effective at A$10,723 per LYG and at A$11,485 per QALY. Probabilistic sensitivity analysis showed that at A$60,000 and A$151,000 per QALY, the probability that mandatory fortification was the most cost-effective strategy was 79% and 85%, respectively. Threshold analysis of loss of consumer choice indicated that with a compensation value above A$1.21 [assuming a willingness to pay (WTP) threshold of A$60,000 per QALY] or A$3.19 (assuming a WTP threshold of A$151,000 per statistical life-year) per capita per year mandatory fortification would not be cost-effective. Mandatory fortification was found to be cost-effective; however, inclusion of the loss of consumer choice can change this result. Even with mandatory fortification, mean folate intake will remain below the recommended NTD preventive level.