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. [1] Two studies (by Freund et al. [1] and Lubarsky et al. [2]) 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. [3] and Rose et al. [4]) 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, [1] expensive anesthetic drugs, [2] prevention of nausea, [3] and management of postoperative pain. [4]

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 [1] or advance approval of the attending anesthesiologist [2] was required to obtain the more expensive drugs. The former study [1] showed that the paper barriers produced changes that were maintained for 2 yr. The latter study [2] 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 [2] 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

Freund PR, Bowdle TA, Posner KL, Kharasch ED, Burkhart VD: Cost-effective reduction of neuromuscular blocking drug expenditures. Anesthesiology 1997; 87:1044-9.
Lubarsky DA, Glass PSA, Ginsberg B, Dear GDL, Dentz ME, Gan TJ, Sanderson IC, Mythen MG, Dufore S, Pressley CC, Gilbert WC, White WD, Alexander ML, Coleman RL, Rogers M, Reves JG for the SWiPE Group: The successful implementation of pharmaceutical practice guidelines: analysis of associated outcomes and costs savings. Anesthesiology 1997; 86:1145-60.
Cohen MM, Rose DK, Yee DA: Changing anesthesiologists practice patterns-Can it be done? Anesthesiology 1996; 85:260-9.
Rose DK, Cohen MM, Yee DA: Changing the practice of pain management. Anesth Analg 1997; 84:764-72.