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

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BACKGROUND: 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 health care-related carbon emissions. Remote patient management (RPM) may offer a lower carbon and cost alternative while maintaining care quality. METHODS: 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 Creating a Sustainable Canadian Health System in a Climate Crisis (CASCADES) Virtual Care Carbon Accounting Tool. A 1:1 nearest-neighbour matching analysis based on median 1-way travel distance was conducted to mitigate geographic confounding. Bootstrap analyses were used to estimate confidence intervals (CIs) for group differences. RESULTS: Remote optimization resulted in more patients reaching GDMT targets (98% vs 85%) and 62-day faster titration. Patients in the remote arm travelled a median of 140 km vs 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 Canadian dollars [CADs]; 95% CI, -49,806.33 to -2,661.51). A folded F test confirmed greater variance in 1-way trip distances (P < 0.001). CONCLUSIONS: 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 heart failure medication titration using an integrated carbon calculator. CLINICAL TRIAL REGISTRATION: NCT04205513.

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