Heart, Lung and Circulation

The Last Mile: Improving Patient Outcomes within Modern Cardiovascular Medicine

  • Derek P. Chew
    Correspondence address: Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia, 5042, Australia. Tel.: +61 8 8404 2001; fax: +61 8 8404 2150.
    Roy and Marjorie Edwards National Heart Foundation Senior Research Fellow, Adelaide, S.A., Australia

    Cardiovascular Outcomes Research, Flinders University, Adelaide, S.A., Australia

    Cardiovascular Medicine, Flinders Medical Centre, Adelaide, S.A., Australia
    Search for articles by this author
      It is now well recognised that, in many areas of medicine, substantial gaps in clinical care exist despite robust clinical trial data and the careful assimilation of this information into clinical practice guidelines. Those at greatest risk are patients presenting with multiple co-morbidities, and those with advanced age in whom the issues of complexity and limited time available for careful assessment, potentially lead to sub-optimal clinical practice and outcomes. Greater efforts are needed to move the acquired knowledge across the “last mile”, that is from clinical guidelines and best practice to nationwide routine practice. This article will discuss some of issues faced in operationalising “clinical effectiveness” in cardiovascular care in Australia.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Huynh L.T.
        • Phillips P.A.
        • Chew D.P.
        Improving the management of acute coronary syndromes in Australia: translating evidence to outcomes.
        Intern Med J. 2007; 37: 412-415
        • Bhatt D.L.
        • Roe M.T.
        • Peterson E.D.
        • Li Y.
        • Chen A.Y.
        • Harrington R.A.
        • Greenbaum A.B.
        • Berger P.B.
        • Cannon C.P.
        • Cohen D.J.
        • Gibson C.M.
        • Saucedo J.F.
        • Kleiman N.S.
        • Hochman J.S.
        • Boden W.E.
        • Brindis R.G.
        • Peacock W.F.
        • Smith Jr., S.C.
        • Pollack Jr., C.V.
        • Gibler W.B.
        • Ohman E.M.
        for the CRUSADE Investigators Utilization of early invasive management strategies for high-risk patients with non-ST-elevation acute coronary syndromes: results from the CRUSADE quality improvement initiative.
        JAMA. 2004; 292: 2096-2104
        • Avezum A.
        • Makdisse M.
        • Spencer F.
        • Gore J.M.
        • Fox K.A.
        • Montalescot G.
        • Eagle K.
        • White K.
        • Mehta R.
        • Knobel E.
        Impact of age on management and outcome of acute coronary syndrome: observations from the global registry of acute coronary events (GRACE).
        Am Heart J. 2005; 149: 67-73
        • Chew D.P.
        • Amerena J.V.
        • Coverdale S.G.
        • Rankin J.M.
        • Astley C.M.
        • Soman A.
        Brieger DB, on behalf of the ACACIA investigators invasive management and late clinical outcomes in contemporary Australian management of acute coronary syndromes: observations from the ACACIA registry.
        Med J Aust. 2008; 188: 691-697
        • Mukherjee D.
        • Fang J.
        • Chetcuti S.
        • Moscucci M.
        • Kline-Rogers E.
        • Eagle K.A.
        Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes.
        Circulation. 2004; 109: 745-749
        • Ho P.M.
        • Spertus J.A.
        • Masoudi F.A.
        • Reid K.J.
        • Peterson E.D.
        • Magid D.J.
        • Krumholz H.M.
        • Rumsfeld J.S.
        Impact of medication therapy discontinuation on mortality after myocardial infarction.
        Arch Intern Med. 2006; 166: 1842-1847
        • Spertus J.A.
        • Kettelkamp R.
        • Vance C.
        • Decker C.
        • Jones P.G.
        • Rumsfeld J.S.
        • Messenger J.C.
        • Khanal S.
        • Peterson E.D.
        • Bach R.G.
        • Krumholz H.M.
        • Cohen D.J.
        Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry.
        Circulation. 2006; 113: 2803-2809
        • Fox K.A.
        • Anderson F.A.J.
        • Dabbous O.H.
        • Steg P.G.
        • Lopez-Sendon J.
        • Van de Werf F.
        • Budaj A.
        • Gurfinkel E.P.
        • Goodman S.G.
        Brieger D and on behalf of the GRACE Investigators Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The global registry of acute coronary events (GRACE).
        Heart. 2007; 93: 177-182
        • Eagle K.A.
        • Montoye C.K.
        • Riba A.L.
        • DeFranco A.C.
        • Parrish R.
        • Skorcz S.
        • Baker P.L.
        • Faul J.
        • Jani S.M.
        • Chen B.
        • Roychoudhury C.
        • Elma M.A.
        • Mitchell K.R.
        • Mehta R.H.
        American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan; American College of Cardiology Foundation (Bethesda Maryland) Guidelines Applied in Practice Steering committee. Guideline-based standardized care is associated with substantially lower mortality in medicare patients with acute myocardial infarction: The American College of Cardiology's guidelines applied in practice (GAP) projects in Michigan.
        J Am Coll Cardiol. 2005; 46: 1242-1248
        • Bradley E.H.
        • Herrin J.
        • Wang Y.
        • Barton B.A.
        • Webster T.R.
        • Mattera J.A.
        • Roumanis S.A.
        • Curtis J.P.
        • Nallamothu B.K.
        • Magid D.J.
        • McNamara R.L.
        • Parkosewich J.
        • Loeb J.M.
        • Krumholz H.M.
        Strategies for reducing the door-to-balloon time in acute myocardial infarction.
        N Engl J Med. 2006; 355: 2308-2320
        • Redfern J.
        • Ellis E.
        • Briffa T.
        • Freedman S.B.
        Modular prevention of heart disease following acute coronary syndrome (ACS).
        BMC Cardiovasc Disord. 2006; 6: 26