Carbon and Travel Cost Reduction From Remote Medication Titration for Advanced Heart Failure: A Secondary Analysis of a Randomized Controlled Trial

Optimization of guideline-directed medical therapy (GDMT) in heart failure with reduced ejection fraction (HFrEF) often requires frequent in-person visits, contributing to patient burden and healthcare-related carbon emissions. Remote patient management (RPM) may offer a lower-carbon and cost alternative while maintaining care quality. This is a secondary analysis of the Medly Titrate randomized controlled trial comparing RPM-based remote GDMT titration with usual care. Carbon emissions and patient travel costs were estimated using the CASCADES Virtual Care Carbon Accounting Tool. A 1:1 nearest-neighbor matching analysis based on median one-way travel distance was conducted to mitigate geographic confounding. Bootstrap analyses were used to estimate confidence intervals for group differences. Remote optimization resulted in more patients reaching GDMT targets (98% vs. 85%) and 62-day faster titration. Patients in the remote arm traveled a median of 140 km versus 213 km in usual care. Matched analysis showed significant reductions in total carbon emissions (-8.50 tonnes; 95% CI -34.58 to -1.84), travel distance (-41,923.53 km; 95% CI -170,491.85 to -9,064.21), and travel costs (-$12,258.78 CAD; 95% CI -49,806.33 to -2,661.51). A folded F test confirmed greater variance in one-way trip distances (P < 0.001). Remote GDMT titration reduced travel, carbon emissions, and costs while maintaining care quality. This study is the first to quantify environmental and financial savings from remote HF medication titration using an integrated carbon calculator.