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.

Abstract

Cardiac rehabilitation (CR) is an outpatient model of secondary prevention that improves patient outcomes, yet use remains limited. Hybrid/alternative CR addresses these challenges, but global availability, structure, and volumes have not been characterized since the pandemic. The International Council of Cardiovascular Prevention and Rehabilitation's (ICCPR) 2025 Audit Update is a cross-sectional survey of phase II CR programs worldwide. After member Associations supported identification of countries with CR, program data were collected via REDCap between May-September/2025. Data were compared by country income classification, and with prior ICCPR Audits where possible. Of 6,905 CR programs identified globally, 1,505 initiated a survey (median program response rate = 62.3% per country) from 90/113 (79.6%) countries with CR. Globally, 286 (23.2%) programs in 40 (35.4%) countries reported reimbursement for hybrid/alternative models, varying significantly by country income class (p < 0.001); this was higher than 2016 (14.5%), but not significantly different from the pandemic (21.0%). 285 (31.1%) programs reported offering a hybrid/alternative CR model, in 57 (50.4% with CR) countries (higher in lower-middle income countries, then upper-middle income countries [UMICs]). This was not higher than previous Audits. Programs were staffed by exercise professionals, nurses and physicians (more in UMICs). Dose was a median of 10 sessions (one/week over 8 weeks), lower than centre-based, but consistent across income classes and over time. Patients were allocated to model based on clinical criteria, choice (69.5%), but also cost (30.2%; higher in middle-income countries and than 2016). Hybrid/alternative models served a median of 50 (P25-P75 = 10-100) patients/program annually, lower than centre-based (median = 135; p < 0.001); volumes were higher in UMICs. 160 (45.8%) programs perceived insufficient capacity to meet demand, most commonly due to staffing and funding. Hybrid/alternative CR availability has not increased since 2016, and decreased since the pandemic. Reimbursement drives availability, but remains limited and inadequate, frequently shifting costs to patients, constraining services and limiting equitable scale-up.