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Improving Single Maintenance and Reliever Therapy for Patients Admitted for Asthma Exacerbation
Katherine A Pumphrey1, Jessica K Hart2, Joseph J Zorc2,3
1From the Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
Insights
Single maintenance and reliever therapy (SMART) is now recommended for children with persistent asthma. This quality improvement project successfully increased SMART prescriptions at discharge for pediatric asthma patients, improving equitable care.
Area of Science:
- Pediatric pulmonology
- Quality improvement science
- Health equity research
Background:
- Single maintenance and reliever therapy (SMART) is guideline-recommended for school-aged children with poorly controlled persistent asthma in the US.
- Pediatric inpatient providers are crucial for prescribing SMART to high-risk asthma patients.
- Existing SMART prescription rates at discharge were suboptimal (17%), necessitating targeted interventions.
Purpose of the Study:
- To increase the proportion of SMART prescriptions at discharge for eligible pediatric asthma patients from 17% to 40% by September 2023.
- To ensure equitable improvements in SMART prescribing across diverse patient populations (payor type, race, Child Opportunity Index).
- To address key drivers of SMART prescription: prescriber familiarity, culture, decision support, and logistics.
Main Methods:
- A quality improvement project utilizing 10 Plan-Do-Study-Act cycles.
- Interventions focused on education and clinical decision support to address identified drivers.
- Inclusion criteria: pediatric patients with inhaled controller medication, and ≥2 asthma exacerbation-related hospitalizations/ER visits within 12 months.
Main Results:
- SMART prescription at discharge increased from 17% to 38% and was sustained for 19 months.
- The increase was observed across demographic strata, including Black patients, those with government insurance, and those with low Child Opportunity Index.
- The project involved 312 hospital encounters for 215 unique pediatric patients between January 2021 and December 2023.
Conclusions:
- Quality improvement methodology effectively increased SMART prescriptions at discharge for pediatric asthma exacerbation.
- The interventions demonstrated success in reducing disparities in asthma care.
- Sustained improvements in SMART prescribing contribute to better asthma management in pediatric populations.
Introduction:
In 2020, single maintenance and reliever therapy (SMART) became guideline-recommended care for school-age children in the United States with poorly controlled, persistent asthma. Pediatric inpatient providers are well positioned to prescribe SMART, as they often care for patients with poorly controlled asthma. Our interdisciplinary team aimed to increase the proportion of SMART prescriptions at discharge for eligible pediatric patients admitted for asthma exacerbation from 17% to 40% by September 2023, consistent across strata of payor type, race, and Child Opportunity Index (COI).
Methods:
Four primary drivers of SMART prescription at discharge were identified: familiarity, prescriber culture, decision support, and logistics. Interventions targeting these drivers, including education and clinical decision support, were implemented during 10 Plan-Do-Study-Act cycles. This quality improvement project included patients who were prescribed an inhaled controller medication on admission and had 2 or more hospitalizations and/or emergency room visits for asthma exacerbation requiring systemic corticosteroids within 12 months. The outcome measure was SMART prescription at discharge, stratified by payor type, race, and COI.
Results:
Between January 2021 and December 2023, 312 hospital encounters involving 215 unique patients occurred. SMART prescription at discharge increased from 17% at baseline to 38% and was sustained for 19 months. Similar increases in SMART prescriptions at discharge were observed among Black patients, those with government-sponsored health insurance, and those with very low COI.
Conclusions:
Using quality improvement methodology, SMART prescriptions increased at discharge for pediatric patients admitted for asthma exacerbation, including in demographic strata where disparities are often observed.
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