Many patients who could benefit from cardiac rehabilitation never receive it, according to led by Rachael Carson, a PhD candidate in 91亚色's Faculty of Health.
As cardiovascular disease remains one of the leading causes of illness and death worldwide, cardiac rehabilitation (CR) programs have been shown to reduce mortality, lower hospital readmissions and improve quality of life.
Despite its proven value, significant gaps remain in who is referred to cardiac rehabilitation and who ultimately participates, particularly in parts of the world where cardiovascular disease places a disproportionate burden on health systems and patients.
"Even when CR programs are available, patients still face barriers to being referred, accessing programs and affording care," says Carson. "Understanding these gaps helps identify where changes in healthcare systems and policies could improve access, particularly in lower-resource settings.鈥
Previous studies had tracked barriers to cardiac rehabilitation and identified disparities in participation across countries and health care systems. However, the COVID-19 pandemic significantly disrupted CR delivery and access worldwide, says Carson. As a result, the global cardiac rehabilitation landscape had not been comprehensively assessed in the years since, with little recent data available on referral practices, wait times, funding models and the costs individuals face when seeking care.
"An updated audit was therefore needed to understand what CR looks like globally today, where progress has been made, and where gaps in referral and access persist,鈥 says Carson.
Under the supervision of 91亚色 Professor Sherry L. Grace and Adjunct Professor Gabriela Ghisi, Carson conducted a global survey of CR programs in 2025 examining referral practices, limitations to participation, wait times, strategies to improve entry to treatment, funding models and patient costs.
The researchers ultimately received survey responses from 1,505 CR programs across 90 countries. Program leaders completed questionnaires about how care is delivered, how people utilize services and the financial challenges both patients and providers face. The researchers then analyzed the results by country income level.
Among the study's observations was the limited adoption of systematic referral systems, which automatically refer eligible individuals to cardiac rehabilitation rather than relying on a clinician to manually make the referral.
"It was striking that systematic referral, despite being an effective way to increase CR use, was implemented in only about one-fifth of programs globally," says Carson.
The finding also reflected one of the study's broader themes: inequity in access. Systematic referral was far more common in high-income countries than in middle- and low-income countries, with programs in high-income countries estimating that roughly 80 per cent of eligible patients were referred to rehabilitation compared with about 50 per cent in middle-income countries.
The study also found that access was shaped not only by referrals, but by whether patients could afford to participate.
"One finding that stood out to me was the magnitude of the financial barriers," says Carson. "Programs globally estimated that 50 per cent of indicated patients may forego CR because of out-of-pocket costs."
Nearly half of surveyed programs relied on direct patient payments as a source of funding. When patients were required to pay, they covered an average of about 60 per cent of rehabilitation costs themselves. In lower-middle-income countries, patients often paid the entire cost of care out of pocket.
Together, the findings point to a broader inequity. Many of the countries carrying the greatest burden of cardiovascular disease also face some of the greatest barriers to rehabilitation, meaning access to treatment known to improve survival and quality of life can depend on where patients live and what they can afford.
The study also highlighted efforts already underway to improve participation. Researchers found that many programs are taking steps to make cardiac rehabilitation more accessible, including by providing information in multiple formats, offering plain-language educational materials, tailoring services to diverse populations and making resources available in different languages with the support of multilingual staff or interpreters.
Building on this progress, the researchers say addressing the persistent inequities identified in the study will require broader policy action. They recommend stronger public investment in CR, expanded health care coverage to reduce out-of-pocket costs and wider use of systematic referral systems to help more who are eligible for care. Those changes could extend the benefits of cardiac rehabilitation to more patients who need it and ultimately help reduce cardiovascular illness and death.
For Carson, the hope is that her work will help inform practical changes that improve access to care for patients around the world.
"I hope these findings help inform changes in policy and clinical practice that make CR more accessible and affordable," says Carson. "Ultimately, improving referral processes and reducing financial barriers could allow more patients to benefit from cardiac rehabilitation."