Ensuring cardiac rehabilitation access for the majority of those in need: A call to action for Canada

Cardiac rehabilitation (CR) is proven model of secondary prevention. Indicated cardiac conditions for CR are well-established, and participation of these patient groups results in significantly lower mortality and morbidity when compared to usual care. There are approximately 170 CR programs in Canada, and this varies widely by province. There is grossly insufficient capacity to treat all indicated patients in Canada, and beyond. Density of CR services is about half what is observed in the United States, at 1 program per 208,823 inhabitants, or 1 program per 7,779 cardiac patients. Despite the Canadian Cardiovascular Society target of 85% referral of indicated cardiac inpatients, significantly fewer patients are referred to CR. Moreover, certain patient groups, such as women, ethnocultural minorities and those of low socioeconomic status are less likely to access CR, despite greater need due to poorer outcomes. CR appears to be reaching a healthier population, who are perhaps more adherent to secondary prevention recommendations, and hence in less need of the limited CR spots available. The reasons for CR under-utilization are well-established, and include factors at the patient, referring provider, CR program and health system-levels. A Cochrane review has established some effective interventions to increase CR utilization, and these must be implemented more broadly. We must advocate for CR reimbursement. Finally, we must re-allocate our CR resources to patients in the greatest need. This may involve risk stratification, with subsequent allocation of lower-risk patients to a more widely-available, lower-cost, and effective alternative model of CR. Summary Cardiac rehabilitation (CR)works, in Canada and beyond. CR is under-used, particularly by those who need it most. Strategies to increase CR use have been established, but they must be widely implemented. CR capacity needs to be greatly increased, and this can potentially be achieved by greater CR reimbursement, as well as more efficient approaches to patient stratification and program model allocation. We must establish lower-cost models of delivery for lower-risk patients.