Table 1
CR availability by country (N = 111), survey response and COVID-19 burden.
| WHO Region Country | Number of CR programsa | CR density§,a | Number of survey responses (%) | Mean date of survey completion (DD/MMM/2020) | COVID cases at mean date of survey completionb | COVID restrictionsc | CR delivery interrupted n (%) |
|---|---|---|---|---|---|---|---|
| African | |||||||
| Algeria | 1 | 2556 | 1 (100.0%) | 09/Jun | 10,265 | 86.57 | NR |
| Nigeria | 1 | 4480 | 8 (100.0%)* | 15/May | 5,162 | 80.56 | 5 (100.0%) |
| South Africa | 23 | 52 | 1 (4.3%) | 30/Apr | 5,350 | 87.96 | 1 (100.0%) |
| Subtotal | 25 | – | 10 (40.0%) | – | – | – | 6 (100.0%) |
| Americas | |||||||
| Argentina | 23 | 3 | 1 (4.3%) | 26/Apr | 3,767 | 98.15 | NR |
| Barbados | 1 | 13 | 2 (100.0%)* | 14/May | 85 | 81.48 | 1 (100.0%) |
| Brazil | 75 | 98 | 27 (36.0%) | 11/May | 162,699 | 81.02 | 19 (100.0%) |
| Canada | 170 | 2 | 39 (22.9%) | 12/May | 69,981 | 70.83 | 18 (64.3%) |
| Chile | 10 | 23 | 12 (100.0%)* | 24/May | 65,393 | 78.24 | 10 (90.9%) |
| Colombia | 50 | 4 | 16 (32.0%) | 29/Apr | 5,949 | 90.74 | 12 (92.3%) |
| Costa Rica | 6 | 12 | 9 (100.0%)* | 04/May | 739 | 72.22 | 3 (60.0%) |
| Cuba | 8 | 35 | 1 (12.5%) | 25/Apr | 1,285 | 83.33 | 1 (100.0%) |
| Ecuador | 5 | 29 | 1 (20.0%) | 11/May | 19,559 | 86.11 | 1 (100.0%) |
| Honduras | 2 | 274 | 3 (100.0%)* | 08/May | 1,685 | 100.0 | 0 (0.0%) |
| Mexico | 59 | 27 | 4 (6.8%) | 04/May | 23,471 | 82.41 | 4 (100.0%) |
| Paraguay | 3 | 25 | 3 (100.0%) | 20/May | 829 | 94.44 | 2 (100.0%) |
| Peru | 10 | 20 | 2 (20.0%) | 11/May | 67,307 | 92.59 | 2 (100.0%) |
| USA | 2685† | 3 | 414 (15.4%) | 23/May | 1,60 million | 72.69 | 238 (85.0%) |
| Uruguay | 12 | 4 | 1 (8.3%) | 20/May | 738 | 61.11 | 1 (100.0%) |
| Subtotal | 3084 | – | 535 (17.3%) | – | – | – | 312 (84.6%) |
| Eastern Mediterranean | |||||||
| Bahrain | 1 | 8 | 2 (100.0%)* | 19/May | 7,184 | 75.00 | 2 (100.0%) |
| Iran | 34 | 15 | 5 (14.7%) | 30/Apr | 93,657 | 56.48 | 3 (75.0%) |
| Kuwait | 1 | 31 | 1 (100.0%) | 01/Jun | 27,043 | 84.26 | 1 (100.0%) |
| Morocco | 1 | 635 | 1 (100.0%) | 08/May | 5,548 | 93.52 | 1 (100.0%) |
| Pakistan | 4 | 104 | 1 (25.0%) | 27/Apr | 13,328 | 89.81 | 1 (100.0%) |
| Qatar | 1 | 37 | 1 (100.0%) | 07/Jun | 67,195 | 83.33 | 1 (100.0%) |
| Saudi Arabia | 1 | 335 | 2 (100.0%)* | 26/May | 74,795 | 91.67 | 0 (0.0%) |
| Tunisia | 1 | 335 | 1 (100.0%) | 24/Apr | 918 | 90.74 | NR |
| Subtotal | 44 | – | 14 (31.8%) | – | – | – | 9 (81.8%) |
| Europe | |||||||
| Austria | 7† | 6 | 7 (100.0%) | 28/Apr | 15,256 | 78.70 | 7 (100.0%) |
| Belarus | 5 | 59 | 1 (20.0%) | 06/Jun | 46,868 | 13.89 | 1 (100.0%) |
| Bosnia and Herzegovina | 1 | 10 | 1 (100.0%) | 09/May | 2,070 | 90.74 | 0 (0.0%) |
| Croatia | 3 | 9 | 3 (100.0%) | 15/May | 2,221 | 70.37 | 3 (100.0%) |
| Czech Republic | 15 | 22 | 3 (20.0%) | 10/May | 8,095 | 54.63 | 2 (66.7%) |
| Denmark | 35 | 3 | 1 (2.9%) | 08/Jun | 11,948 | 62.96 | 1 (100.0%) |
| Estonia | 2 | 37 | 2 (100.0%) | 06/May | 1,711 | 75.00 | 1 (100.0%) |
| Finland | 25 | 11 | 1 (4.0%) | 27/Apr | 4,576 | 57.41 | 1 (100.0%) |
| France | 130 | 4 | 22 (16.9%) | 09/Jun | 154,188 | 65.74 | 3 (60.0%) |
| Georgia | 17 | 2 | 7 (41.2%) | 06/May | 604 | 96.30 | 5 (83.3%) |
| Greece | 4 | 153 | 1 (25.0%) | 26/Apr | 2,506 | 84.26 | 1 (100.0%) |
| Hungary | 33 | 4 | 12 (36.4%) | 11/May | 3,284 | 62.96 | 7 (77.8%) |
| Ireland | 37 | 1 | 33 (89.2%) | 08/May | 22,385 | 90.74 | 27 (96.4%) |
| Israel | 22 | 1 | 2 (9.1%) | 02/May | 16,101 | 84.26 | 1 (100.0%) |
| Italy | 221 | 5 | 12 (5.4%) | 05/May | 211,938 | 62.96 | 7 (87.5%) |
| Lithuania | 25 | 1 | 1 (4.0%) | 29/Apr | 1,344 | 77.78 | 1 (100.0%) |
| Malta | 1 | 2 | 1 (100.0%) | 28/Apr | 450 | NR | 1 (100.0%) |
| Moldova | 1 | 53 | 2 (100.0%)* | 09/Jun | 9,807 | 80.56 | 0 (0.0%) |
| Netherlands | 90 | 2 | 2 (2.2%) | 29/Apr | 38,416 | 79.63 | 0 (0.0%) |
| Norway | 35 | 41 | 2 (5.7%) | 10/May | 8,069 | 64.81 | 2 (100.0%) |
| Portugal | 23 | 16 | 3 (13.0%) | 03/May | 25,190 | 87.96 | 3 (100.0%) |
| Romania | 3 | 17 | 1 (33.3%) | 26/Apr | 10,635 | 87.04 | 1 (100.0%) |
| Serbia | 2 | 13 | 3 (100.0%)* | 13/May | 10,243 | 93.52 | 2 (100.0%) |
| Slovak Republic | 7 | 21 | 1 (14.3%) | 10/May | 1,455 | 73.15 | 1 (100.0%) |
| Slovenia | 2 | 37 | 3 (100.0%)* | 14/May | 1,464 | 53.24 | 2 (100.0%) |
| Spain | 87 | 17 | 5 (5.7%) | 02/May | 217,804 | 85.19 | 4 (100.0%) |
| Sweden | 69 | 5 | 38 (55.1%) | 28/May | 35,088 | 46.30 | 13 (68.4%) |
| Turkey | 10 | 97 | 3 (30.0%) | 01/May | 120,204 | 75.93 | 3 (100.0%) |
| United Kingdom (includes Guernsey) | 365 | – | 59 (16.2%) | 08/May | 206,715 | 75.93 | 20 (48.8%) |
| England | 266 | 2 | 41 (15.4%) | 10/May | 138,759 | – | – |
| Guernsey | NR | NR | 1 (NR) | 28/Apr | 247 | – | – |
| Northern Ireland | 13 | 3 | 2 (15.4%) | 27/Apr | 3,374 | – | – |
| Scotland | 69 | 1 | 9 (13.0%) | 12/May | 13,763 | – | – |
| Wales | 17 | 2 | 6 (35.3%) | 30/Apr | 10,362 | – | – |
| Subtotal | 1642 | – | 232 (14.1%) | – | – | – | 120 (75.9%) |
| South-East Asian | |||||||
| Bangladesh | 1 | 2046 | 1 (100.0%) | 15/May | 18,863 | 89.81 | 0 (0.0%) |
| India | 23 | 360 | 44 (100.0%)* | 21/May | 112,359 | 79.17 | 19 (90.5%) |
| Indonesia | 13 | 51 | 4 (30.8%) | 01/May | 10,118 | 80.09 | 3 (75.0%) |
| Nepal | 1 | 22 | 2 (100.0%)* | 05/Jun | 2,634 | 92.59 | 1 (100.0%) |
| Thailand | 5 | 200 | 2 (40.0%) | 06/Jun | 3,104 | 57.41 | 1 (100.0%) |
| Subtotal | 43 | – | 53 (100.0%) | – | – | – | 24 (85.7%) |
| Western Pacific | |||||||
| Australia | 314 | 1 | 69 (22.0%) | 07/May | 6,875 | 69.44 | 30 (53.6%) |
| Brunei Darussalam | 2 | 3 | 1 (50.0%) | 22/May | 141 | 52.78 | 1 (100.0%) |
| China | 216 | 44 | 53 (24.5%) | 03/Jun | 84,159 | 78.24 | 25 (48.1%) |
| Japan | 325 | 5 | 1 (0.3%) | 31/May | 16,851 | 31.48 | NR |
| Malaysia | 6 | 58 | 5 (83.3%) | 14/May | 6,779 | 69.44 | 3 (100.0%) |
| New Zealand | 43 | 2 | 27 (62.8%) | 14/May | 1,147 | 36.11 | 20 (87.0%) |
| Philippines | 10 | 39 | 9 (90.0%) | 11/May | 10,794 | 96.30 | 8 (100.0%) |
| Singapore | 7 | 5 | 8 (100.0%)* | 05/May | 18,778 | 85.19 | 4 (100.0%) |
| South Korea | 17 | 22 | 8 (47.1%) | 13/May | 10,962 | 43.52 | 0 (0.0%) |
| Taiwan | 35 | 7 | 19 (54.3%) | 05/May | 438 | 27.78 | 2 (16.7%) |
| Subtotal | 975 | – | 200 (20.5%) | – | – | – | 93 (56.4%) |
| Total | 5813 | – | 1044 (18.0%)‡ | 18/May° | 4.68 million | – | 570 (76.2%) |
[i] Note: Valid frequency and percentage shown.
NR, not reported; USA, United States of America; CR, cardiac rehabilitation; COVID-19, coronavirus disease 2019.
– not applicable.
a As per ICCPR’s Global CR Audit [26].
b Information retrieved from the website https://ourworldindata.org/.
c Government Response Stringency Index ranges from 0 to 100, with 100 = strictest responses.
* Number of respondents surpassed the number of CR programs previously identified.
† Received updated information regarding number of programs in country since ICCPR’s global audit.
§ Represents number of CR spots available per year per incident ischemic heart disease patient (higher numbers represent worse density; i.e., 1 CR ‘spot’ per n patients).
‡ 16 respondents did not identify which country they are from.
° Average date of survey completion.
Table 2
Cardiac rehabilitation program adaptations due to COVID-19 by World Health Organization region.
| WHO region | Total | ||||||
|---|---|---|---|---|---|---|---|
| Africa | Americas | Eastern Mediterranean | Europe | South-East Asian | Western Pacific | ||
| Reducing some elements offered | 3 (30.0%) | 110 (20.6%) | 3 (21.4%) | 57 (24.6%) | 10 (18.9%) | 43 (27.0%) | 228 (19.5%) |
| Only treating existing patients | 2 (33.3%) | 100 (41.3%) | 4 (57.1%) | 51 (46.8%) | 14 (63.6%) | 29 (33.3%) | 202 (17.3%) |
| Deferring graduation until post-program assessments can be completed | 2 (20.0%) | 71 (13.3%) | 2 (14.3%) | 21 (9.1%) | 3 (5.7%) | 19 (12.3%) | 120 (10.3%) |
| Shortening the program duration | 3 (30.0%) | 46 (8.6%) | 1 (7.1%) | 18 (7.8%) | 4 (7.5%) | 22 (14.1%) | 95 (8.2%) |
| Graduating patients more quickly | 2 (20.0%) | 57 (10.7%) | 1 (7.1%) | 7 (3.0%) | 2 (3.8%) | 14 (9.2%) | 85 (7.3%) |
| None of the above; we are adapting all elements to retain service levels. | 2 (20.0%) | 91 (17.0%) | 6 (42.9%) | 31 (13.4%) | 12 (22.6%) | 35 (21.6%) | 177 (15.1%) |
[i] Note 1: Valid frequency and percentage shown; respondents instructed to check all that apply.
Note 2: Total does not sum the values from WHO regions because some respondents did not report their country.
WHO, World Health Organization.
Table 3
CR components provided in the programs and that continued to be provided during the COVID-19 pandemic.
| Offered and continue to be offered during COVID-19 | Offered, but not during COVID-19 | Never offered | |
|---|---|---|---|
| Initial assessment | 371 (45.3%) | 390 (47.6%) | 58 (7.1%) |
| Individual consultation with a doctor or nurse | 356 (44.0%) | 335 (41.4%) | 118 (14.6%) |
| Exercise stress test | 144 (18.3%) | 288 (36.5%) | 357 (45.2%) |
| Other functional capacity test | 166 (20.9%) | 438 (55.2%) | 189 (23.8%) |
| Exercise prescription | 375 (46.0%) | 386 (47.3%) | 55 (6.7%) |
| Supervised exercise training | 208 (25.5%) | 521 (63.9%) | 86 (10.6%) |
| Resistance training | 224 (27.9%) | 480 (59.8%) | 99 (12.3%) |
| Patient education | 445 (54.4%) | 331 (40.5%) | 42 (5.1%) |
| Management of cardiovascular risk factors | 436 (54.6%) | 320 (40.1%) | 42 (5.3%) |
| Prescription/titration of secondary prevention medications | 271 (33.9%) | 250 (31.3%) | 278 (34.8%) |
| Nutrition counseling | 352 (43.4%) | 377 (46.5%) | 82 (10.1%) |
| Psychological counseling | 298 (37.3%) | 301 (37.7%) | 199 (24.9%) |
| Smoking cessation sessions/classes | 199 (25.1%) | 344 (43.3%) | 251 (31.6%) |
| Sexual counselling | 134 (17.2%) | 219 (28.2%) | 424 (54.6%) |
| Vocational counseling/support for return-to-work | 166 (21.3%) | 238 (30.6%) | 374 (48.1%) |
| Stress management/Relaxation techniques | 260 (32.6%) | 370 (46.4%) | 168 (21.1%) |
| Alternative forms of exercise (e.g., yoga, dance, or tai chi) | 94 (12.1%) | 174 (22.4%) | 508 (65.5%) |
| Inclusion of family/informal caregivers | 179 (22.5%) | 465 (58.6%) | 150 (18.9%) |
| End of program re-assessment | 245 (30.4%) | 449 (55.7%) | 112 (13.9%) |
| Communication of patient assessment results with their primary care provider | 322 (40.5%) | 342 (43.0%) | 132 (16.6%) |
| Follow-up after outpatient program | 198 (25.3%) | 294 (37.5%) | 292 (37.2%) |
| Maintenance program | 147 (18.7%) | 404 (51.3%) | 236 (30.0%) |
| Other (e.g., telephone sessions, mindfulness sessions) | 36 (10.8%) | 30 (9.0%) | 268 (22.2%) |
[i] Note: Valid frequency and percentage shown.
CR, cardiac rehabilitation.
Table 4
Alternative models of CR delivery.
| Yes, before COVID-19 | Yes, during COVID-19 | No | |
|---|---|---|---|
| Reimbursement of alternative models | 102 (12.7%) | 67 (8.3%) | 636 (79.0%) |
| Alternative models offered | 150 (18.5%) | 172 (21.2%) | 488 (60.2%) |
| Proportion of patients served in remote model | 16.5 ± 24.5% | 69.0 ± 37.2% | n/a |
| Perceive program has sufficient capacity to meet need/demand for remote delivery | 142 (49.1%) | 155 (54.0%) | 121 (42.2%) |
| Forms of Communication | |||
| Phone | 178 (62.2%) | 96 (33.6%) | 12 (4.2%) |
| 128 (46.9%) | 88 (32.2%) | 57 (20.9%) | |
| Internet webpage | 104 (38.4%) | 99 (36.5%) | 68 (25.1%) |
| Text messages | 93 (34.8%) | 42 (15.7%) | 132 (49.4%) |
| Smartphone app | 52 (20.6%) | 67 (26.6%) | 133 (52.8%) |
| Webcam/videoconference (e.g., education sessions) | 37 (14.2%) | 105 (40.4%) | 118 (45.4%) |
| Other | 14 (15.6%) | 6 (6.7%) | 70 (77.8%) |
[i] Note: frequency and percentage or mean and standard deviation shown.
n/a = not applicable; CR = cardiac rehabilitation.
Table 5
COVID-19 impacts by World Health Organization region.
| WHO region | Total | ||||||
|---|---|---|---|---|---|---|---|
| Africa | Americas | Eastern Mediterranean | Europe | South-East Asia | Western Pacific | ||
| Program has had suspected or positive COVID-19 cases | 3 (50.0%) | 47 (12.9%) | 5 (55.6%) | 32 (20.6%) | 3 (10.7%) | 13 (8.0%) | 106 (14.4%) |
| Restrictions on staff work, travel, or home life | 4 (66.7%) | 251 (68.0%) | 9 (81.8%) | 98 (62.0%) | 17 (58.6%) | 94 (57.3%) | 481 (64.3%) |
| Concern about delivering CR due to lack of PPE | 5 (83.3%) | 71 (19.5%) | 2 (18.2%) | 45 (28.8%) | 15 (51.7%) | 44 (27.2%) | 182 (24.6%) |
| Felt need to work despite perceived risk for fear of losing job or pay | 4 (66.7%) | 149 (41.0%) | 2 (18.2%) | 43 (27.9%) | 12 (41.4%) | 63 (38.2%) | 276 (37.3%) |
| No paid sick leave | 1 (16.7%) | 74 (20.7%) | 3 (27.3%) | 15 (9.7%) | 12 (41.4%) | 45 (27.3%) | 150 (20.4%) |
| Institution giving staff information so can perform duties safely | 6 (100.0%) | 335 (93.1%) | 10 (100.0%) | 143 (92.9%) | 29 (100.0%) | 163 (98.8%) | 696 (94.6%) |
| Staff Changes | |||||||
| Re-deployed | 4 (40.0%) | 203 (37.9%) | 7 (50.0%) | 87 (37.5%) | 5 (9.4%) | 41 (25.6%) | 353 (30.2%) |
| Reduced hours | 4 (40.0%) | 163 (30.5%) | 4 (28.6%) | 16 (6.9%) | 4 (7.5%) | 21 (13.5%) | 215 (18.5%) |
| Some staff have had to practice somewhat outside their scope | 3 (30.0%) | 80 (15.0%) | 7 (50.0%) | 41 (17.7%) | 4 (7.5%) | 21 (13.5%) | 159 (13.7%) |
| Laid off temporarily | 1(10.0%) | 96 (17.9%) | 4 (28.6%) | 21 (9.1%) | 4 (7.5%) | 12 (7.8%) | 138 (11.9%) |
| Pay reductions | 3 (30.0%) | 36 (6.7%) | 4 (28.6%) | 10 (4.3%) | 5 (9.4%) | 13 (8.2%) | 71 (6.1%) |
| Permanently let go | 1 (10.0%) | 14 (2.6%) | 0 (0.0%) | 6 (2.6%) | 1 (1.9%) | 2 (1.0%) | 24 (2.1%) |
| Other | 0 (0.0%) | 24 (4.5%) | 0 (0.0%) | 8 (3.4%) | 2 (3.8%) | 9 (6.0%) | 43 (3.7%) |
[i] Note 1: Frequency and valid percentage shown.
Note 2: Total does not sum the values from WHO regions because some respondents have not reported their countries.
WHO, World Health Organization; PPE, personal protective equipment.
Figure 1
Psychological impacts on CR staff due to COVID-19.
Note: Other feelings included anger, fear, frustration, exhaustion, sadness, stress.
Figure 2
Perceived risk in contacting COVID-19 through their CR work by country.
Figure 3
Factors that respondents perceive should form the basis for resumption of face-to-face CR services given COVID-19.
Note: respondents instructed to check all that apply.