Clinician and family perspectives on the use of single maintenance and reliever therapy for children.

BACKGROUND

Single maintenance and reliever therapy (SMART) is the guideline-recommended treatment for children with moderate to severe asthma, yet it is underutilized in pediatric practice.

OBJECTIVE

To understand barriers and facilitators to SMART adoption within pediatric practice.

METHODS

We interviewed 52 participants (16 pediatricians, 22 parents, and 16 children). Interviews were conducted until theme saturation, recorded, transcribed, coded, and qualitatively analyzed using the Consolidated Framework for Implementation Research.

RESULTS

We identified barriers, facilitators, and potential solutions to SMART implementation. Participants described barriers at the following levels: (1) the clinic level, which included a lack of clinician training and clinical decision support for SMART; (2) the family level, which included discomfort transitioning away from traditional albuterol and concern about SMART's effectiveness as a rescue medication; and (3) the school and systems levels, which included poor communication and a lack of aligned care plans across community settings like schools, and challenges navigating insurance coverage. Facilitators to SMART implementation included acceptance of SMART as a simpler treatment that could improve asthma symptoms. Proposed solutions to barriers included the following: (1) clinic-level trainings and integrated clinical decision support; (2) family-level support for reluctant families; and (3) clear communication between clinics and schools, access to SMART-specific medication orders and action plans, and insurance support.

CONCLUSION

Most pediatricians and families reported that SMART is a favorable, simple, and acceptable treatment approach for children with asthma. However, pediatricians and families described significant barriers to using guideline-concordant SMART in routine practice. These results could inform targeted efforts to improve the adoption of SMART within pediatric asthma care.