Physician Connecticut Children's Medical Center Hartford, Connecticut, United States
Background: Despite the potential for public health benefits, Single Maintenance and Reliever Therapy (SMART) in pediatric asthma is infrequent in the United States, particularly in pediatric primary care, which is where most children with asthma access healthcare. Supporting primary care physicians (PCPs) in the adoption of asthma guidelines is the goal of the standardized, evidence-based asthma management program, Easy Breathing. In addition to appropriate screening and diagnosis of asthma, provision of asthma treatment plans (ATPs) is a key element. The provision of written ATPs improves outcomes in asthma and is recommended for all patients. Nevertheless, whether PCPs who use Easy Breathing and trained in SMART therapy accurately write and distribute SMART ATPs is unknown. Objective: The purpose of this study was to assess the quality of SMART ATPs among a sample of PCPs who have implemented Easy Breathing, and thus SMART, in their practice. Design/Methods: From August 2021 to September 2023, PCPs (n=11) trained in a standardized asthma management program (Easy Breathing) provided SMART ATPs to children with asthma. An audit-and-feedback approach was applied to evaluate whether SMART ATPs were consistent with updated NAEPP guidelines. A pediatric pulmonologist, pediatrician, and certified asthma educator reviewed and discussed the accuracy of ATPs. Results: Thirty two SMART ATPs were provided to children who were on average 10 years (±4.3) old. PCP-determined asthma severity was: mild persistent (n=5), moderate persistent (n=23), severe persistent (n=3), unknown severity (n=1). All PCPs accurately wrote SMART instructions for maintenance use (E.g. “budesonide/formoterol 2 puffs twice a day with a spacer”). However, for reliever use, the majority of providers (n=20, 63%) prescribed short-acting β-agonist (i.e. albuterol) rather than budesonide/formoterol. There was significant variability in the dose and frequency of budesonide/formoterol used for reliever use (e.g. “1 puff every 4 hours” vs “1 inhalation as needed every 10 minutes”).
Conclusion(s): The majority of pediatricians seem unable to transition away from albuterol as rescue. Even if providers switch to SMART, they continue to use the dosing frequency consistent with albuterol reliever rather than SMART prescribing. PCPs need more assistance de-implementing old practices when new, paradigm-shifting guidelines are introduced.
