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.