Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia
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In 2009, mandatory folic acid fortification of bread-making flour was introduced in Australia to reduce the birth prevalence of preventable neural tube defects (NTDs) such as spina bifida. Before the introduction of the policy, modelling predicted a reduction of 14–49 NTDs each year.
Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia.
We developed a decision tree model to compare different fortification strategies and used registry data to quantify the change in NTD rates due to the policy. We adopted a societal perspective that included costs to industry and government as well as healthcare and broader societal costs.
We found 32 fewer NTDs per year in the post-mandatory folic acid fortification period. Mandatory folic acid fortification improved health outcomes and was highly cost effective because of the low intervention cost. The policy demonstrated improved equity in outcomes, particularly in birth prevalence of NTDs in births from teenage and indigenous mothers.
This study calculated the value of mandatory folic acid fortification using real-world registry data and demonstrated that the attained benefit was comparable to the modelled expected benefits. Mandatory folic acid fortification (in addition to policies including advice on supplementation and education) improved equity in certain populations and was effective and highly cost effective for the Australian population.
Liz Chinchen (CHERE, UTS), Research Manager, assisted with the literature search.
SS, PH, NvdL and SG designed the research; SS, PH, KM and EM conducted the research and performed the analysis; SS, PH and NvdL wrote the manuscript; and KM, EM and SG reviewed the manuscript. All authors read and approved the final manuscript.
Compliance with Ethical Standards
This study was funded by the Australian Health Ministers’ Advisory Council (AHMAC), Department of Health.
Conflict of interest
SS, PH, NvdL, KM, EM and SG have no conflicts of interest that are directly relevant to the content of this article. NvdL is now employed at AstraZeneca Netherlands.
- 1.FSANZ. Proposal P295: Consideration of mandatory fortification with folic acid: Final Assessment Report. Food Standards Australia and New Zealand; 2006.Google Scholar
- 4.Access Economics. Cost benefit analysis of fortifying the food supply with folic acid. Food Standards Australia New Zealand; 2006.Google Scholar
- 5.Access Economics. Fortification of bread with folic acid. Food Standards Australia New Zealand; 2006.Google Scholar
- 6.Hilder L. Neural Tube Defects in Australia, 2007–2011: Before and after implementation of the mandatory folic acid fortification standard. New South Wales: University of New South Wales, National Perinatal Epidemiology and Statistics Unit; 2016.Google Scholar
- 7.FSANZ. Proposal P295 Consideration of mandatory fortification with folic acid: first review report Food Standards Australia and New Zealand; 2007.Google Scholar
- 8.Australian Health Ministers’ Advisory Council. The effectiveness and cost-effectiveness of mandatory folic acid and iodine fortification 2017.Google Scholar
- 9.Australian Institute of Health and Welfare. Monitoring the health impacts of mandatory folic acid and iodine fortification. Canberra: AIHW; 2016.Google Scholar
- 13.Kelly A, Haddix A, Scanlon K, Helmick C, Mulinare J. Cost-effectiveness of strategies to prevent neural tube defects. In: Gold M, Siegel J, Russell L, Weinstein M, editors. Cost-effectiveness in health and medicine. Oxford: Oxford University Press; 1996. p. 313–48.Google Scholar
- 18.FSANZ. Monitoring the Australian population’s intake of dietary folic acid before and after mandatory fortification Canberra. 2016.Google Scholar
- 19.Catalyst Ltd. Report of stage 1: a review of compliance with, and enforcement impacts of the mandatory fortification of bread with folic acid and iodine. Department of Health; 2015.Google Scholar
- 20.Australian Bureau of Statistics. 3101.0—Australian demographic statistics, Jun 2015. 2015. http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3101.0Sep%202015?OpenDocument. Accessed 15 Apr 2016.
- 21.Australian Bureau of Statistics. 3301.0—Births, Australia, 2014. 2015. http://www.abs.gov.au/ausstats/abs@.nsf/mf/3301.0. Accessed 15 Apr 2016.
- 22.Australian Bureau of Statistics. 3302.0.55.001—Life tables, States, Territories and Australia, 2012–2014. 2014. http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3302.0.55.0012012-2014?OpenDocument. Accessed 15 Apr 2016.
- 23.Australian Government Department of Health. Guidelines for preparing a submission to the Pharmaceutical Benefits Advisory Committee (Version 5.0): Australian Government; 2016.Google Scholar
- 24.Macaldowie A, Hilder L. Neural tube defects in Australia: prevalence before mandatory folic acid fortification. Canberra: AIHW; 2011.Google Scholar
- 32.National Hospital Cost Data Collection. National Hospital Cost Data Collection Cost Weights for AR-DRG Version 6.0x, Round 16 (2011–12), Public Hospital 2012. https://www.ihpa.gov.au/publications/nhcdc-australian-public-hospitals-cost-report-2011-2012-round-16. Accessed 15 Apr 2016.
- 34.IHPA. National Hospital Cost Data Collection, Public Hospitals Cost Report, Round 19 (Financial year 2014–15).Google Scholar
- 35.Medicare Benefits Schedule. Medicare benefits schedule book: operating from 01 November 2014. Australian Government Department of Health; 2014.Google Scholar
- 37.AIHW National Hospital Morbidity Database. Separation statistics by principal diagnosis (ICD-10-AM 8th edition), Australia, 2013–14. http://www.aihw.gov.au/hospitals-data/principal-diagnosis-data-cubes/. Accessed 15 Apr 2016.
- 39.Australian Bureau of Statistics. 4433.0.55.006 Disability and Labour Force Participation: ABS; 2012. http://www.abs.gov.au/ausstats/abs@.nsf/mf/4433.0.55.006. Accessed 08 June 2016.
- 40.Food and Drug Administration. Food additives permitted for direct addition to food for human consumption; folic acid. Final rule. Fed Regist. 2016;81(73):22176–83.Google Scholar