Global cardiac rehabilitation stalls as cardiovascular disease keeps climbing

Cardiovascular disease continues to tighten its grip on global health, yet the programs proven most effective at helping patients survive and recover have barely expanded in a decade. That is the central finding of a new study led by researchers at York University in Toronto, published in the journal PLOS One, which reports that despite mounting evidence of benefit and a steadily growing population of people living with chronic heart disease, the worldwide availability of cardiac rehabilitation programs has stagnated over the past ten years. The analysis, conducted as part of the International Council of Cardiovascular Prevention and Rehabilitation’s 2025 Global Audit Update, offers the first post-pandemic global assessment of hybrid and alternative delivery models for cardiac rehabilitation, and its numbers reveal a widening gap between where the disease burden falls and where services exist.

Cardiac rehabilitation is not a luxury intervention. It is a structured chronic disease management program, typically beginning in the hospital and continuing as an outpatient service before transitioning into longer-term community-based secondary prevention. The programs combine supervised exercise, education on healthy living, and stress counselling, and they are designed to improve outcomes for patients recovering from cardiac events or living with ongoing cardiovascular disease. The evidence base is robust: participation reduces mortality by more than 25 percent and hospitalization by nearly 20 percent. Multiple studies have also documented improvements in quality of life and reductions in hospital readmissions. In clinical terms, few interventions in cardiovascular medicine deliver so much benefit for so relatively little cost, which is precisely why the new findings have unsettled the researchers behind them.

The audit identified close to 7,000 cardiac rehabilitation programs across 90 countries. Within that total, 1,233 programs in 40 countries provided detailed information about hybrid and alternative delivery models, which blend clinic-based and home-based care and are generally cheaper to operate and easier for patients to attend. Of those 1,233 programs, only 286 indicated that they received reimbursement from governments or insurance companies for hybrid or alternative delivery. Overall, hybrid and alternative models accounted for roughly one third of all programs offered globally, and only about one quarter of them were reimbursed. For the study’s authors, including York University and University of Toronto Adjunct Professor Gabriela Lima de Melo Ghisi, York Professor Sherry Grace of the Faculty of Health, and graduate student Rachael Carson, the picture is one of under-utilization in the face of proven effectiveness.

Perhaps the most striking pattern in the data is the mismatch between disease burden and program availability when countries are sorted by income classification. In high-income nations, the ratio of programs to cases of ischemic heart disease, while imperfect, reflects at least a meaningful infrastructure. Canada recorded 72,849 cases of ischemic heart disease in 2023 alongside 380 programs. The United States reported 1,144,557 incidents and 2,687 programs. Japan counted 292,531 incidents against 678 programs, and Germany 362,984 incidents against 155 programs. These figures vary considerably in per-case coverage, but they stand in sharp contrast to the situation in low-income countries, where the audit found programs essentially absent despite significant caseloads.

Afghanistan, for example, recorded 34,207 incidents of ischemic heart disease and zero cardiac rehabilitation programs. Ethiopia reported 28,903 incidents and, likewise, no programs. Malawi emerges as an outlier in the dataset, with 3,872 incidents and 23 programs, a small but notable exception that suggests expansion is possible even in resource-constrained settings. The researchers emphasize that the highest levels of chronic cardiac disease now occur in low- and middle-income countries, where roughly 80 percent of global cardiovascular deaths take place. Lima de Melo Ghisi notes that this concentration not only increases economic pressures on those countries but also places further burdens on health-care systems that are often already stretched thin. The absence of rehabilitation capacity in exactly the places where need is greatest amounts to a structural inequity in global cardiovascular care.

The barriers to expansion are neither mysterious nor purely scientific. The study identifies the lack of funding and staffing as the major roadblock, with costs frequently falling on patients themselves, which reinforces inequity. Beyond financing, practical obstacles shape who can actually attend: the distance patients live from program centers, the availability of transportation, particularly in rural areas, and the competing demands of work and family life that leave little room for regular clinic visits. These constraints have driven interest in home-based and hybrid programs, which are less expensive to run, easier for people to access, and, according to existing comparative research, capable of delivering outcomes comparable to clinic- or hospital-based models. Yet even this more flexible tier of service has not grown. Since the pandemic, the number of hybrid and alternative programs has actually decreased, even as more people worldwide survive cardiac events and live longer with cardiovascular disease.

That post-pandemic contraction is one of the study’s most disheartening findings, and the researchers say they were surprised by it. Hybrid models were widely expected to be a growth area, accelerated by the shift toward remote care during COVID-19 lockdowns. Instead, the audit suggests that without committed reimbursement, even the cheaper delivery formats fail to achieve financial sustainability. The reimbursement figures are telling: with only about a quarter of hybrid and alternative programs funded by governments or insurers, the economic case for establishing and maintaining them remains fragile. Where patients must pay out of pocket, uptake drops, and where uptake drops, the programs struggle to justify institutional investment, creating a self-reinforcing cycle of under-provision.

The methodological approach of the audit gives its findings considerable weight. Rather than extrapolating from a handful of national registries, the researchers tallied programs across 90 countries, recorded the level of reimbursement where available, and compared countries by income class, producing a standardized global snapshot that had not existed since before the pandemic. Published as a data and statistical analysis in PLOS One under the title describing delivery of cardiac rehabilitation through hybrid models and alternative settings by country income classification and decade, the study provides a baseline against which future expansion, or continued stagnation, can be measured. The decade-over-decade comparison is what allows the authors to state plainly that availability has not increased worldwide despite rising incidence of cardiovascular disease.

What emerges from the analysis is a clear prescription. The results point to the need not only for increased implementation of cardiac rehabilitation programs but for more sustained reimbursement, which the researchers argue would go a long way toward providing cardiovascular care globally. In practice, that means health systems and insurers recognizing hybrid and home-based delivery as fundable services rather than experimental add-ons, and it means targeted investment in low- and middle-income countries where the disease burden is heaviest and the infrastructure thinnest. Carson’s summary of the paradox is blunt: multiple studies have already shown that cardiac rehabilitation works, playing an outsized role in reducing mortality, hospital readmissions, and improving quality of life, and yet the programs remain under-utilized. Closing that gap, the study suggests, is less a question of clinical science than of policy, financing, and the political will to fund secondary prevention at the scale the global burden of cardiovascular disease now demands.

For the millions of people living with chronic cardiac disease, the stakes of that policy shift are concrete. Every unreimbursed program and every country without services represents patients who could have reduced their risk of death by a quarter but were never given the option. The 2025 Global Audit Update makes the scale of the shortfall measurable for the first time in the post-pandemic era, and it hands clinicians, policymakers, and funders a precise map of where the work must happen next.

Subject of Research: Global availability and reimbursement of cardiac rehabilitation programs compared with rising cardiovascular disease burden

Article Title: Cardiac rehabilitation programs not keeping up with global increases in cardiovascular disease

Article References: Cardiac rehabilitation programs not keeping up with global increases in cardiovascular disease. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: cardiac rehabilitation, cardiovascular disease, global health, health equity, hybrid care models, reimbursement, low-income countries, ischemic heart disease, secondary prevention, PLOS One, York University, global audit