The scale of the unimplemented backlog is striking. Between 2008 and 2016, the Colombian Ministry of Health funded the development of 58 national clinical practice guidelines, produced to high methodological standards and drawing on the research capacity of universities, hospitals, professional societies and patient organizations. Those guidelines collectively contain 3,887 individual recommendations, but implementation remains in its early stages. The researchers attribute the shortfall to the sheer number of recommendations, limited stakeholder experience in implementation science, and a wide range of practical barriers that have never been systematically mapped for Colombian decision-makers.

To decide where to focus, the team engaged representatives of the Colombian Ministry of Health in structured dialogues about which recommendations deserved priority. Using a previously developed visualization tool that ranks pending recommendations, the group selected two clinical areas judged to have significant potential impact on health outcomes, provider experience and health system resources. The first concerned the management of ST-elevation myocardial infarction, the most dangerous form of heart attack, specifically the provision of early fibrinolysis when primary percutaneous coronary intervention cannot be delivered within the recommended time windows. The second concerned rehabilitation services for people with limb amputations, a population that in Colombia includes thousands of victims of antipersonnel landmines left by decades of armed conflict.

The clinical stakes of the first brief are considerable. Early fibrinolysis, the administration of clot-dissolving drugs, is the recommended coronary reperfusion option for patients with ST-elevation myocardial infarction who cannot reach a facility capable of primary percutaneous coronary intervention within 12 hours of symptom onset, or who cannot obtain medical assistance within 90 minutes. The intervention reduces the risk of death and reinfarction by up to 20 percent and improves mid- and long-term outcomes. Given the low availability of catheterization laboratories across Colombia, the country’s challenging geography, and persistent barriers to coronary care, the authors argue that early fibrinolysis may be the best reperfusion option for most Colombian heart attack patients. Between 2011 and 2019, the country recorded 288,169 deaths from myocardial infarction, yet no Colombian study has quantified how many patients lack access to the therapy.

Using the SUPPORT methodology for evidence-informed policymaking, the researchers systematically searched PubMed, Health Systems Evidence and five additional databases, together with grey literature, between February and May 2021. For the fibrinolysis brief, 271 records were screened and 33 studies were included, spanning 48 countries across low-, middle- and high-income settings. Twenty-one of those studies addressed barriers to implementation, ten addressed facilitators and twenty-five described strategies for overcoming obstacles. For the rehabilitation brief, 573 records were screened and 45 studies were included, with 23 studies addressing strategies for adherence to policy recommendations in low- and middle-income countries and 23 covering comprehensive care and continuity of rehabilitation services. Quality was appraised with tools matched to study design, including AMSTAR II for systematic reviews, AGREE GRS for guidelines and Joanna Briggs Institute checklists for other designs.

The barriers identified in the fibrinolysis brief operate at three levels. At the patient level, delayed consultation driven by poor recognition of heart attack symptoms accounts for roughly two-thirds of delays in receiving reperfusion, and low socioeconomic status, low educational attainment, rural residence, transportation difficulties and lack of insurance all reduce access to treatment. At the provider level, clinicians struggle with lengthy guidelines poorly adapted to local contexts, and many lack the training and confidence to interpret electrocardiograms and administer fibrinolytic therapy, a problem especially acute among general practitioners in rural areas where no cardiologist is available. At the system level, the brief documents fragmented care, administrative delays tied to insurance, scarce human resources and equipment, high costs of fibrin-specific drugs, weak audit and feedback mechanisms, and insufficient funding and priority setting for noncommunicable diseases.

The most consequential strategy to emerge from the evidence is the establishment of regional coronary care networks that integrate community facilities with highly complex hospitals along predetermined reperfusion pathways. Such networks, which have driven improvements in countries from Canada to Egypt to India, allow timely fibrinolysis in peripheral settings while opening a 24-hour window for referral to a percutaneous intervention centre for pharmaco-invasive therapy. Complementary strategies include public education campaigns on symptom recognition delivered through mass media and text messaging, training programs for prehospital and hospital staff, quality monitoring between institutions, government-covered insurance for heart attack care, and investment in health information systems that enable reliable audit and feedback.

The rehabilitation brief tells a parallel story of systemic failure. Colombia’s armed conflict has left 8,451 people amputated by antipersonnel mines between 1990 and July 2021, and the World Health Organization and United Nations have both called on member states to strengthen rehabilitation services. Yet preliminary Colombian data cited in the study reveal the depth of the access problem: among 85 individuals with amputations studied in ongoing research, prostheses were prescribed for only 15 patients, or 17.6 percent, and just 3 patients, or 3.5 percent, actually received one. The average wait between amputation and prosthesis prescription was 147 days, and the interval between amputation and delivery of the device ranged from four to eight months. Barriers include inadequate funding, fragmentation in which each rehabilitation intervention occurs in a different location, deficient information systems, and insufficient training among health workers in amputee care.

The evidence points to concrete remedies. Telehealth, telerehabilitation and tele-education programs were accepted by patients and improved follow-up, knowledge and outcomes, an important finding for rural populations far from rehabilitation centres, and trials in other chronic conditions suggest telerehabilitation is not inferior to in-person care. Home-based training by community volunteers improved independence, mobility and social integration, while structured programs with clear goals and feedback improved the rehabilitation experience. At the provider level, multidisciplinary teams, better care pathways and economic incentives reduced major amputations and improved service delivery. One review found that patients who received prostheses were more likely to receive extensive outpatient therapy and experienced fewer hospitalizations and emergency visits.

The unifying conclusion of both briefs is that Colombia’s implementation challenge is fundamentally one of access, continuity and coordination. Nineteen percent of Colombians live in rural areas and nearly 40 percent of the rural population lives in poverty, making strategies that improve timely access for rural and low-income communities essential. The authors conclude that networks integrating community facilities and hospitals, with clear healthcare pathways that help patients navigate the system and clarify each stakeholder’s role, could positively and significantly affect outcomes and care experience for both heart attack patients and amputees. They also emphasize that the education sector is central, since building the knowledge and skills of both patients and providers is a precondition for any of these reforms. As a methodological contribution, the study demonstrates that evidence briefs, though less rigorous than formal systematic reviews, are a practical tool for translating a backlog of 3,887 dormant recommendations into prioritized, actionable implementation plans.

Subject of Research: Development of evidence briefs to support implementation planning for early fibrinolysis in myocardial infarction and rehabilitation services for amputee patients in Colombia

Article Title: Using evidence briefs to support future implementation planning: the case of early fibrinolysis for myocardial infarction and rehabilitation for the amputee patient in Colombia

Article References: Vélez, M., Vélez-Marín, V., Lugo-Agudelo, L. H., Patiño Lugo, D. F., Velásquez-Salazar, P., Mesa Franco, L. F., Vera-Giraldo, C. Y., Velásquez-Correa, J. C., Fahim, C., Marten, R., Yangchen, S., & Straus, S. (2026). Using evidence briefs to support future implementation planning: the case of early fibrinolysis for myocardial infarction and rehabilitation for the amputee patient in Colombia. Health Research Policy and Systems, 24(S1), Article 70. https://doi.org/10.1186/s12961-026-01466-5

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01466-5

Keywords: evidence briefs, implementation science, clinical practice guidelines, early fibrinolysis, ST-elevation myocardial infarction, rehabilitation, amputee care, Colombia, health policy, coronary care networks, telerehabilitation, health systems