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Barriers to Implementing SMART for Asthma in Pediatric Primary Care
Julia Peled1, Sherry Dodd2, Sharon Graham2
1Division of Allergy and Pulmonology, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
Pediatrics
|July 1, 2026
Summary
Pediatric clinicians know about single maintenance and reliever therapy (SMART) for asthma but face many barriers to using it. System and caregiver issues hinder SMART adoption and removing older treatments.
Area of Science:
- Pediatric Asthma Management
- Implementation Science
- Primary Care Research
Background:
- Single Maintenance and Reliever Therapy (SMART) is a guideline-recommended asthma treatment.
- Barriers to SMART implementation in pediatric primary care are not fully understood.
Purpose of the Study:
- To assess awareness, use, and barriers to SMART in primary care for children.
- To identify clinician, system, and caregiver factors influencing SMART adoption.
Main Methods:
- Mixed-methods study involving surveys and interviews with pediatric primary care clinicians.
- Utilized the Consolidated Framework for Implementation Research (CFIR) 2.0 for analysis.
Main Results:
- Universal awareness of SMART, but limited prescribing in eligible children.
- Clinicians perceive SMART as effective but face operational and system barriers (e.g., insurance, prior authorization).
- Caregiver resistance and lack of SMART-specific action plans impede implementation.
Conclusions:
- Pediatric clinicians support SMART but encounter significant multilevel barriers.
- Implementation strategies should address clinician, system, and caregiver factors.
- EHR-integrated SMART action plans and practice facilitation may improve uptake.
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