Despite rising incidents of cardiovascular disease (CVD), along with evidence that cardiac rehabilitation programs improve outcomes for those living with CVD, availability of these programs has not increased worldwide in the past decade, according to a new study by York University researchers.
Availability even for the more affordable hybrid or alternative cardiac rehabilitation programs has not increased since 2016 and is lower than during the pandemic.
The researchers, including York University and University of Toronto Adjunct Professor Gabriela Lima de Melo Ghisi, York Professor Sherry Grace of the Faculty of Health, and York grad student Rachael Carson, are surprised and disheartened by the results.
From Left, York and UofT Adjunct Professor Gabriela Lima de Melo Ghisi and York grad student Rachael Carson
Cardiac rehabilitation is a chronic disease management program proven to reduce death by more than 25 per cent and hospitalization by almost 20 per cent. These programs often begin with patients in the hospital and continue as an outpatient service before moving into a longer-term community-based secondary prevention service. Hybrid programs are both clinic and home-based and are designed to improve outcomes for patients and can involve exercise, healthy living education and stress counselling.
"More people around the world are surviving cardiovascular events and living longer with chronic heart disease, yet access to cardiac rehabilitation remains inadequate," says Lima de Melo Ghisi. "Hybrid and alternative models can help overcome barriers such as distance and transportation, but our findings show that gains made during the pandemic have not been sustained. Limited reimbursement, staffing and funding continue to constrain these services and contribute to inequities in access."
Without adequate funding, the costs to run the programs often fall to patients and those in rural areas are particularly disadvantaged if the program is far from where they live.
"Multiple studies have already shown that cardiac rehabilitation programs work, playing an outsized role in reducing mortality, hospital readmissions and improving quality of life," says Carson of York's Faculty of Health. "Despite that, these programs are under-utilized."
The paper, Delivery of cardiac rehabilitation through hybrid models and alternative settings by country income classification and decade: Comparisons from the International Council of Cardiovascular Prevention and Rehabilitation's 2025 Global Audit Update, was published today in the journal PLOS One.
It is the first global post-pandemic assessment of hybrid and alternative cardiac rehabilitation programs. The number of programs were tallied, including level of reimbursement for them, and countries were compared by income class. Close to 7,000 cardiac rehabilitation programs were identified in 90 countries, but only 286 out of 1,233 programs in 40 of those countries indicated they received reimbursement for the hybrid/alternative models of delivery by government or insurance companies.
In high-income countries like Canada, there were 72,849 cases of ischemic heart disease in 2023 and 380 programs. For the United States, there were 1,144,557 incidents and 2,687 programs. In Japan, there were 292,531 incidents and 678 programs and in Germany there were 362,984 and 155 programs.
Compare this to low-income countries like Afghanistan with 34,207 incidents and zero programs, Ethiopia with 28,903 incidents and zero programs, and outlier Malawi with 3,872 incidents and 23 programs.
Overall, about one-third of responding cardiac rehabilitation programs reported offering a hybrid or alternative model, while fewer than one-quarter reported reimbursement for these models. Among programs offering hybrid or alternative care, almost half (45.8 per cent) reported insufficient capacity to meet demand, most commonly because of staffing and funding constraints.
The results point to the need for not only increased implementation of these programs but for more sustained reimbursement which would go a long way in providing cardiovascular care globally.
