Global Audit Reveals Stagnant Hybrid Cardiac Rehabilitation Availability and Persistent Reimbursement Barriers

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Summary of  PLOS ONE  https://doi.org/10.1371/journal.pone.0359951
Dr. Gabriela L. M. Ghisi et al.

Points

York University and University of Toronto researchers conducted a global audit evaluating nearly seven thousand cardiac rehabilitation programs across ninety countries following the pandemic.
Systematic survey data revealed that hybrid and alternative rehabilitation models represent approximately one third of global programs but suffer from widespread funding and staffing shortages.
Financial analysis confirmed that only twenty three percent of reporting alternative cardiac rehabilitation programs receive formal government or private insurance reimbursement worldwide.
High income nations maintain hundreds to thousands of established cardiac rehabilitation centers while low income countries like Afghanistan and Ethiopia lack active rehabilitation programs entirely.
Authors concluded that establishing sustained reimbursement frameworks is critical to scale up hybrid cardiac rehabilitation and reduce secondary cardiovascular mortality globally.

Summary

This study evaluated the global availability, reimbursement, and delivery models of cardiac rehabilitation (CR) programs following the COVID-19 pandemic. Published in PLOS One by researchers from York University and the University of Toronto, the International Council of Cardiovascular Prevention and Rehabilitation’s 2025 Global Audit Update examined the landscape across varying country income classifications. Given that 80% of global cardiovascular deaths occur in low- and middle-income countries (LMICs) and evidence demonstrates CR reduces mortality by over 25% and hospitalizations by nearly 20%, the study sought to determine whether hybrid and alternative CR models expanded to meet growing disease burdens.

The audit identified nearly 7,000 CR programs operating across 90 countries, with hybrid and alternative models comprising approximately one-third of all active programs worldwide. However, reimbursement for these flexible models remains severely constrained, with only 286 out of 1,233 reporting programs across 40 countries receiving government or insurance reimbursement (23.2%). Significant geographic disparities persisted between high-income nations and low-income regions; for instance, the United States reported 1,144,557 cases of ischemic heart disease (IHD) in 2023 supported by 2,687 CR programs, Canada reported 72,849 IHD cases with 380 programs, Japan recorded 292,531 cases with 678 programs, and Germany documented 362,984 cases with 155 programs. Conversely, low-income nations like Afghanistan (34,207 IHD cases) and Ethiopia (28,903 IHD cases) reported zero active CR programs, with rare outliers such as Malawi offering 23 programs for 3,872 cases.

The authors conclude that global availability of hybrid and alternative CR has stagnated since 2016 and contracted post-pandemic, primarily due to persistent reimbursement deficits and inadequate public funding. In the absence of sustainable reimbursement mechanisms, the financial burden shifts directly to patients, creating profound global inequities in secondary cardiovascular prevention. Expanding sustained public and private reimbursement for hybrid CR models is essential to scale up cost-effective secondary prevention and reduce mortality worldwide.

Link to the article: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0359951

References

Ghisi, G. L. M., Carson, R. P., Adawi, K. T., Ding, R., Rivero, M. C., Anchique, C. V., Schalkwijk, D. L. van, Gallagher, J., Mettananda, C., Fernández, R., Aimakova, G. T., Kim, W.-S., Seron, P., Jiandani, M. P., Martinez, J., Maskhulia, L., Batalik, L., Akinci, B., Chen, S.-Y., … Investigators, on behalf of the I. G. C. R. A. U. (2026). 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. PLOS ONE, 21(10), e0359951. https://doi.org/10.1371/journal.pone.0359951