A patient recovering from a heart attack may leave hospital with instructions to exercise safely, manage medication and reduce future cardiovascular risk. Yet the practical work of recovery often requires repeated appointments, transport and time away from employment or family responsibilities.
Home-based cardiac rehabilitation is intended to reduce some of those obstacles. A global audit published on 9 October 2026 suggests that funding arrangements have not kept pace with the potential for delivering structured recovery programmes outside conventional hospital clinics.
Among 1,233 rehabilitation programmes answering the relevant funding question, just 286, or 23.2%, reported that government or insurance reimbursement was available for hybrid or alternative models in their region. That does not mean only 23.2% of all programmes worldwide receive funding, because the figure describes responding programmes.
The findings come from a peer-reviewed study in PLOS One, led by Gabriela L. M. Ghisi and Sherry L. Grace with an international research team. It draws on the International Council of Cardiovascular Prevention and Rehabilitation’s 2025 Global Audit Update.
The researchers identified 6,905 cardiac rehabilitation programmes internationally and received initiated surveys from 1,505. Responses came from 90 of the 113 countries where phase II cardiac rehabilitation services were confirmed to exist.
The central finding is not that home-based recovery has failed clinically. It is that payment, staffing and programme capacity remain substantial obstacles to making flexible cardiac rehabilitation an ordinary part of healthcare delivery.
What cardiac rehabilitation actually provides
Cardiac rehabilitation is more than advice to become physically active. A qualifying phase II programme involves an initial assessment, structured aerobic exercise and at least one additional component addressing risk factors, such as education, dietary guidance or psychosocial support.
The phase II period generally follows hospital discharge. Its purpose is to help patients return to everyday activities while reducing the likelihood of further cardiovascular events through coordinated secondary prevention.
Traditionally, patients attend a clinical centre for supervised exercise and other services. That arrangement can be difficult when a patient lives far from the facility, lacks transport or cannot attend during working hours.
A hybrid programme may begin with an in-person assessment and then combine home exercise with telephone, video or occasional clinic follow-up. Other alternatives use community locations rather than a conventional hospital-based centre.
The audit grouped home-based and hybrid arrangements with other alternative delivery settings. This matters because the results should not be read as an evaluation of smartphone apps alone, or of completely unsupervised exercise.
In fact, only one in five responding programmes offering these alternatives reported prescribing no on-site visits at all. Most retained some physical contact with clinicians, even when much of the rehabilitation occurred elsewhere.
How the international audit was conducted
Researchers collected information between May and September 2025 through an international network of cardiac rehabilitation societies and programme leaders. Programme staff completed an online questionnaire about delivery models, reimbursement, staffing, patient selection and capacity.
The audit was cross-sectional, meaning it captured a snapshot of practice rather than following the same programmes through a controlled intervention. Its comparisons with 2016 and pandemic-era audits use separate samples and therefore require caution.
The investigators classified countries by World Bank income group. They summarised programme responses using counts, percentages and medians, and applied statistical tests to explore differences between income groups and audit periods.
Some analyses used mixed-effects models to account for the fact that programmes within the same country can share health-system conditions. Other comparisons used chi-square or non-parametric tests, with stricter thresholds when multiple comparisons were made.
A total of 1,505 programmes initiated the survey, but not every programme answered every question. As a result, the denominator varies across findings and should be retained when interpreting percentages.
Across participating countries, the median programme response proportion was 62.3%. The breadth of the survey is notable, although non-response means it cannot establish the precise prevalence of each delivery model across every programme worldwide.
Funding was available to a minority of respondents
The most direct funding result was 286 of 1,233 programmes reporting reimbursement for hybrid or alternative cardiac rehabilitation. These programmes were located across 40 countries, equivalent to 35.4% of countries with confirmed cardiac rehabilitation services.
The 23.2% programme figure was higher than the 14.5% reported in the 2016 audit. The difference was statistically significant, but the newer result was not significantly different from the 21.0% reported in the pandemic audit.
In other words, the decade brought some improvement in reimbursement among responding programmes, but it did not establish that flexible rehabilitation had become routinely financed or accessible.
The reimbursement pattern differed by country income group. The study reported a statistically significant association between income classification and reimbursement, with a chi-square statistic of 24.60 and p below 0.001.
Its reported Cramer’s V of 0.141 indicates a small-to-moderate association rather than a complete separation between richer and poorer health systems. Income group alone does not explain every local funding decision.
Even when reimbursement existed, it did not necessarily remove patient costs. Among programmes reporting reimbursement, 130 of 286, or 45.5%, still said patients paid some or all of their programme costs directly.
Where those patients paid, the reported median out-of-pocket share was 35% of total programme cost. Among programmes without reimbursement, the corresponding median share was 60%, a significant difference.
These percentages refer to programme reports, not an independently audited sample of individual patient bills. They nevertheless illustrate why the formal existence of a flexible care option does not guarantee affordability.
Availability was largely unchanged from 2016
Of 1,258 programmes answering the availability question, 371, or 29.5%, said they offered a hybrid or alternative rehabilitation model. That is fewer than one in three of the responding services.
The comparable 2016 audit reported availability in 31.1% of responding programmes. The difference was not statistically significant, suggesting no clear decade-long expansion in the proportion of surveyed programmes offering alternatives.
Among the 371 programmes with alternative models, 269 reported home-based services, 151 offered hybrid arrangements and 141 reported community-based services. These categories overlap because a programme could offer more than one format.
A closer look at how programmes operated showed substantial variation. Initial in-person assessment was common, while some services shifted patients from centre-based exercise to supervised activity at home after an introductory period.
Around 49% of programmes describing hybrid delivery reported continued home-exercise supervision through telephone or telehealth follow-up. Approximately 41% described technology-enabled delivery involving video, apps or remote physiological monitoring.
The figures make an important distinction: flexible rehabilitation does not require sophisticated connected devices in every setting. Telephone calls, paper exercise plans and occasional clinic visits may be relevant where broadband or equipment access is limited.
Availability also varied by country income classification. The study reported a higher proportion of alternative delivery in upper-middle-income countries than high-income countries after its adjusted pairwise comparison.
That pattern should not be interpreted as proof that middle-income systems provide better cardiac care overall. It describes the share of surveyed rehabilitation programmes offering these specific formats, not population access, clinical outcomes or national coverage.
Fewer sessions and smaller patient volumes
The typical hybrid or alternative programme prescribed a median of 10 sessions, with an interquartile range of four to 24. Programmes generally described about one session per week across an eight-week period.
Compared with centre-based services, alternative models prescribed significantly fewer sessions per week and fewer total sessions. The study did not directly test whether those differences produced worse health outcomes for individual patients.
A shorter programme could be appropriate for some patients, but it may also reflect staffing shortages or reimbursement limits. Without patient-level outcome comparisons, the audit cannot distinguish these explanations.
For programmes using a mixture of home and on-site care, the median required number of on-site visits was two. The figure shows that remote delivery often supplements, rather than completely replaces, physical appointments.
The typical programme treated a median of 50 new patients annually through hybrid or alternative delivery. Traditional centre-based services reported a higher median of 135 patients per year.
Reported annual capacity also differed: a median of 70 patients for hybrid or alternative services, compared with 200 for centre-based programmes. Both comparisons were statistically significant in the audit.
These are medians across responding programmes, not national totals. Differences in programme size, referral systems and local healthcare infrastructure mean that the figures should not be used as a simple measure of treatment efficiency.
Nevertheless, they reveal a scale problem. An option intended to make care easier to reach often operated as a relatively small service within the broader rehabilitation system.
Staffing and technology were recurring obstacles
Among 350 programmes answering the capacity question, 160, or 45.8%, said their hybrid or alternative service could not meet demand. The figure was 56.6% among respondents in upper-middle-income countries.
Of the 160 programmes reporting insufficient capacity, 130, or 81.3%, cited too few staff. Inadequate funding was reported by 73, or 45.6%, while 71 identified patients’ risk levels as a constraint on unsupervised exercise.
Technology limitations also appeared, but they were not the only obstacle. Fifty-two capacity-constrained programmes, or 32.5%, identified patients’ lack of technological or other capability.
Separately, 196 of 334 programmes, or 58.7%, perceived communication barriers with patients using alternative delivery. Common problems involved technology access, digital confidence and internet connectivity.
This is why shifting services online is not automatically the same as improving access. A remote appointment can remove a transport barrier while creating a connectivity or device barrier for a different patient.
The audit found that nurses, physiotherapists, physicians and exercise specialists all participated in alternative rehabilitation. Among the 371 programmes offering these models, 52.6% reported nurse contact and 49.3% reported physiotherapist contact.
Physicians interacted directly with patients in 37.7% of programmes, while exercise physiologists or kinesiologists were reported by 35.8%. These percentages reflect reported staff contact, not the full staffing complement of every programme.
Patient support materials were also varied. Educational materials were reported by 67.9% of programmes offering alternative models, activity trackers by 37.7%, and resistance training equipment by 32.3%.
Another 10.5% reported providing no materials for use outside the main clinical centre. The difference matters because home-based rehabilitation relies on clear instructions and practical tools between clinical contacts.
Choice, distance and cost shaped patient selection
Programme leaders commonly cited patient preference, travel distance, transport difficulties and clinical risk when deciding who could enter an alternative model. The study reported patient choice as a factor for about seven in ten programmes.
Cost was also identified as a patient-allocation factor by approximately 30% of programmes, compared with 22.9% in the 2016 audit. That finding illustrates how financial conditions can influence the form of care people receive.
Clinical safety remained important. Among programmes offering alternatives, 54.4% reported accepting moderate-risk patients and 21.6% accepted high-risk patients.
These figures do not mean every patient is suitable for unsupervised home exercise. A rehabilitation plan must account for medical history, symptoms, functional capacity and professional assessment.
The survey also found that programmes generally allocated only around one-fifth of their annual patients to hybrid or alternative care where those models were available. Availability therefore did not necessarily translate into large patient volumes.
For patients, the relevant question is not simply whether a hospital advertises a remote programme. It is whether a funded, clinically appropriate place is available, with enough professional contact and support to complete rehabilitation.
Why the findings matter for South Africa
The global results are relevant to health systems where distance, transport costs and uneven specialist distribution make repeated clinic visits difficult. South Africa faces these practical issues across both urban and rural settings, although this study does not provide a South Africa-specific causal estimate.
A flexible programme could potentially combine an initial clinical assessment with local exercise supervision, telephone check-ins and selected in-person reviews. The audit suggests such arrangements need sustainable financing and staffing, not just a digital platform.
South African funders and healthcare providers should therefore distinguish between paying for a device or app and paying for a comprehensive rehabilitation pathway. Exercise guidance alone does not replace risk-factor management, education and clinically appropriate follow-up.
The study also highlights the importance of low-technology delivery. In communities where data costs, device availability or connectivity are barriers, a telephone-supported or community-based pathway may be more realistic than a video-first model.
Those are policy implications, not interventions tested by the audit in South Africa. Local pilots would need to measure clinical outcomes, patient adherence, costs and equitable access before any national conclusions could be drawn.
What the study cannot establish
This was a survey of service providers rather than a trial assigning patients to different rehabilitation formats. It therefore cannot show that reimbursement caused more programmes to offer home-based care, or that one delivery model improved survival.
Programmes that responded may have had more staff, better infrastructure or stronger links to professional associations than those that did not. This could make the reported availability and reimbursement rates higher than those in the full global programme population.
The 2016, pandemic and 2025 surveys also involved different respondent groups and changing service conditions. Apparent changes across years should not be treated as a perfectly controlled time series.
Several findings depend on self-reported programme practices rather than independently verified invoices, clinical records or patient outcomes. The study also had limited responses from low-income countries, reducing confidence in detailed comparisons for that group.
Its value lies in mapping the practical state of delivery across a wide international sample. It offers evidence about how services are organised and financed, not proof of which individual treatment pathway is medically superior.
A recovery option still waiting to scale
Cardiac rehabilitation is designed to help people manage cardiovascular disease after a serious event. The audit indicates that alternative delivery formats remain relatively uncommon and often small, despite their potential to reduce the burden of repeated travel.
The contrast is stark: 29.5% of responding programmes offered hybrid or alternative models, while just 23.2% reported reimbursement in their region. Nearly half of programmes answering the capacity question said they could not meet demand.
For healthcare planners, the immediate challenge is not simply to persuade more patients to exercise at home. It is to make flexible rehabilitation clinically comprehensive, adequately staffed, affordable and available to the people most likely to struggle with traditional appointments.
The next generation of research will need to test which funding and delivery arrangements can expand participation without sacrificing treatment quality. For now, the international audit shows how far flexible cardiac rehabilitation remains from routine, equitable access.
Source Information
Study title: 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.
Authors: Gabriela L. M. Ghisi, Rachael P. Carson, Karam Turk Adawi, Rongjing Ding, Monserrat Cruz Rivero, Claudia V. Anchique, Dinah L. van Schalkwijk, Jonathan Gallagher, Chamila Mettananda, Rosalia Fernández, and colleagues, on behalf of the ICCPR Global Cardiac Rehabilitation Audit Update Investigators.
Journal: PLOS One, volume 21, issue 10, article e0359951.
Publication date: 9 October 2026.
Study design: International cross-sectional programme survey, with comparisons against earlier global audits.
Data collection: May to September 2025.
Study population: 6,905 programmes identified globally; 1,505 initiated surveys from 90 countries. Question-specific denominators vary, including 1,233 for reimbursement and 1,258 for availability.
Original study DOI: 10.1371/journal.pone.0359951
