Four recent studies in the anesthesia literature have reported successful and similar programs to change anesthesiologists' practice patterns. [1–4] This issue of Anesthesiology contains one such report.  Two studies (by Freund et al.  and Lubarsky et al. ) tested the success of their efforts to change practice patterns by comparing drug use during a historical control period to that in a later intervention period at single hospitals. The other two studies (by Cohen et al.  and Rose et al. ) performed such an analysis at a control and a study hospital. Increases in the proportion of patients treated using the practice guidelines were then compared between the two hospitals. All four studies simultaneously monitored changes in patient demographics and outcomes. The studies examined practice guidelines for neuromuscular blocking drugs,  expensive anesthetic drugs,  prevention of nausea,  and management of postoperative pain. 
Comparison of how these groups achieved changes in anesthesiologists' practice patterns are important. Two studies [1,2] succeeded at changing anesthesiologists' practice patterns by combining education, practice guidelines, and paper barriers. Completion of a form at an operating room pharmacy  or advance approval of the attending anesthesiologist  was required to obtain the more expensive drugs. The former study  showed that the paper barriers produced changes that were maintained for 2 yr. The latter study  discussed that maintenance of the changed behavior was achieved, in part, by providing anesthesiologists with individualized feedback on their (1) deviation from the practice guidelines and (2) drug administration compared with their peers. The other two studies [3,4] succeeded at changing practice patterns by combining education, practice guidelines, and individualized feedback. The individualized feedback included the number of patients cared for during the promoted measures.
Together, the results of these [1–4] studies stand in contrast to some previous studies in anesthesiology that failed to show that education and practice guidelines change physicians' practice patterns. Anesthesiologists' practice patterns can be changed [1–4] to decrease costs, [1,2] to try to improve patient outcome, [3,4] or both. However, changing practice patterns requires more than just education and practice guidelines. Either “negative” barriers limiting undesired practice (e.g., signatures, voice release, or forms), [1,2]“positive” individualized feedback, [3,4] or both  should be combined with education to change physicians' behavior.
Franklin Dexter, M.D., Ph.D.
Associate Professor; Department of Anesthesia; University of Iowa; Iowa City, Iowa 52242