Hybrid and alternative delivery models for cardiac rehabilitation are less expensive and more accessible but globally the number of programs has stagnated creating inequities and increasing the risk of related health issues.

TORONTO, Oct. 9, 2026 鈥� 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 91亚色 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 91亚色 and University of Toronto Adjunct Professor Gabriela Lima de Melo Ghisi, 91亚色 Professor Sherry Grace of the Faculty of Health, and 91亚色 grad student Rachael Carson, are surprised and disheartened by the results.

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.

鈥淢ore people around the world are surviving cardiovascular events and living longer with chronic heart disease, yet access to cardiac rehabilitation remains inadequate,鈥� says Lima de Melo Ghisi. 鈥淗ybrid 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.鈥�

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.

鈥淢ultiple studies have already shown that cardiac rehabilitation programs work, playing an outsized role in reducing mortality, hospital readmissions and improving quality of life,鈥� says Carson of 91亚色鈥檚 Faculty of Health. 鈥淒espite that, these programs are under-utilized.鈥�

The paper, , 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.

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聽TORONTO, May 16, 2016 鈥� Life-saving cardiac rehab programs are not being offered in countries where heart disease is the biggest killer. A panel of experts has now released a statement recommending how all the key elements of these programs can be delivered in an affordable way, in the places where it is needed most.

鈥淎ll heart patients should be referred to cardiac rehab,鈥� says 91亚色 U Professor Sherry Grace. 鈥淲e see in countries like India and China, young cardiac patients die at incredible rates. This is because so few programs are set up in these developing countries.鈥�

Cardiac rehabilitation is an outpatient chronic disease management program, proven to reduce death by over 25 per cent and hospitalization by almost 20 per cent.

Grace led the panel convened through the that has released a statement including recommendations on how all of the key elements of cardiac rehab programs can be delivered at a low cost.

The cardiac rehab model of care is quite standard in developed countries, and consists of risk factor assessment and management, exercise training, patient education, as well as dietary and psychosocial counselling. While it is cost-effective to deliver these programs in countries such as Canada, the United Kingdom and United States, the situation in developing countries is different.

鈥淲e needed to provide direction on how to deliver all these components in an affordable, but effective way,鈥� says Dr. Paul Oh, co-author and medical director of Cardiovascular Prevention and Rehabilitation Program at Toronto Rehabilitation Institute-University Health Network (UHN).

91亚色 U Faculty of Health's Grace and Karam Adawi worked with other experts from Canada, China, India, Iran, Singapore, South Africa, the Middle East and South America on creating the guidelines. They have published the Consensus Statement that includes specific recommendations for delivering each component, drawing from effective cardiac rehabilitation programs in developed countries and also from their own expertise.

鈥淗ealth workers who are not medical doctors can play a key role in providing rehabilitation to cardiac patients,鈥� says co-author Dr. Aashish Contractor, who heads Rehabilitation and Sports Medicine department at Sir H.N. Reliance Foundation Hospital in Mumbai, India. 鈥淎 community health-care worker or nurse can educate and guide patients on making lifestyle changes at a lower-cost than a doctor, and there are just too few doctors in these countries鈥�.

In the statement titled 鈥�, published in the journal , they also recommend that programs not be delivered in expensive medical settings like hospitals, but in the community. New technologies should also be exploited, because the penetration of mobile phones in these countries is very high.

Grace, who is also a Senior Scientist at Toronto Rehabilitation Institute-UHN, adds that plans are underway to test the model and its cost in various countries. 鈥淭hen we can advocate for more cardiac rehab delivery, and refine how we deliver it. We see new cardiac care units going up in these countries; the wealthy receive high-tech interventions like stents and surgery, but the average heart patient is not able to get the low-tech basics that work well in cardiac rehab.鈥�

The statement by the expert panel has been endorsed by many leading organizations, including the British, Australian and Canadian Associations of Cardiovascular Prevention and Rehabilitation, the World Hypertension League, the African Heart Network, and the Singapore Heart Foundation.

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As the world-leading rehabilitation research centre, Toronto Rehabilitation Institute is revolutionizing rehabilitation by helping people overcome the challenges of disabling injury, illness or age related health conditions to live active, healthier, more independent lives. It integrates innovative patient care, ground breaking research and diverse education to build healthier communities and advance the role of rehabilitation in the health system.聽 Toronto Rehab, along with Toronto General and Toronto Western Hospitals, the Princess Margaret Cancer Centre and The Michener Institute for Education at UHN is a member of the University Health Network and is affiliated with the University of Toronto.聽

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