Cardiac rehabilitation referral and access by country income class: Comparisons from the International Council of Cardiovascular Prevention and Rehabilitation's 2025 Global Audit Update.

Abstract

To characterize CR: (1) referral practices, (2) systematic referral barriers, (3) wait listing, (4) program-level approaches to mitigating patient access barriers, as well as (5) CR reimbursement sources; compared by country income classification and Audit decade. A cross-sectional, observational Audit update. Program-level data were collected (May-September 2025) via REDCap survey. Participants were leads from phase II/post-discharge CR programs offering at least initial assessment, structured aerobic exercise, and ≥1 other core component. ICCPR-member Societies and other local leaders facilitated program identification. Survey items pertaining to program and patient costs were standardized to 2025 international dollars using purchasing power parity (PPP) to facilitate comparisons. 1,505/7,025 CR programs identified globally initiated a survey from 90/113 countries with CR. Of programs situated in a hospital, 87% had inpatient cardiology services, most commonly referring before discharge (62%). Programs offered tailored CR information to patients (61%) in multiple formats/modalities. Wait times were consistent with 2016 at 3 weeks. Programs contacted no-shows (67%) and discussed patient-related barriers (63%), with access optimization strategy variation by income class (p<0.05). The most common funding sources were government (63%), patients (45%), and insurance (26%); patient funding was more common in non-high-income countries. Total mean delivery cost was 1,237.6PPP±1972.9/patient/program, with 50% of patients paying 60% of that cost (both varied significantly by income class; p<.05). Programs estimated 50% of patients did not attend CR due to cost (significantly higher in non-HICs: p<0.001). Programs are implementing evidence-based patient engagement approaches, but reimbursement inequities undermine access globally.