Врачи первичного звена сталкиваются с барьерами при внедрении единого ингалятора SMART для лечения астмы у детей

Single maintenance and relief therapy (SMART) is underutilized in asthmatic children treated in primary care, a survey-based clinician study in Pediatrics found. SMART uses a single inhaler combining an inhaled corticosteroid and formoterol, a rapid-acting bronchodilator. Patients use it for daily maintenance and as needed for symptom relief, which reduces flare-ups and simplifies treatment. Despite high awareness and acceptance of SMART’s efficacy and the American Academy of Pediatrics endorsement, primary care survey respondents reported that implementation of these single inhalers faces multiple roadblocks. These barriers include insurance coverage, workflow constraints, lack of specific action plans, and resistance to switching from separate short-acting beta-agonist (SABA) therapy, according to investigators led by Allison A. King, MD, MPH, PhD, professor and Fred M. Saigh Distinguished Chair in Pediatric Research at WashU Medicine in St. Louis and director of the WashU Medicine Pediatric and Adolescent Ambulatory Research Consortium (WU PAARC). “When I took on leadership of WU PAARC about 2 years ago, one of the first things we did was ask the community pediatricians in our network what they most needed to improve care in their own practices. SMART for asthma rose to the top of their list,” King told Medscape Medical News. The clinical backdrop made it compelling since SMART reduces severe asthma exacerbations by about a third and is now recommended in US and international guidelines for children as young as 4 or 5, she said. “Yet most children with asthma are cared for in primary care, and we knew very little about whether and how SMART was actually being used there. We set out to understand the gap between strong evidence and everyday practice.” The Study Conducted during August and September 2025 among pediatric clinicians affiliated with the practice-based WU PAARC, the study invited 189 clinicians to participate. Of these, 52 responded (79% suburban practitioners), and 24 participated in semi-structured follow-up interviews. “Our respondents skewed suburban and cared for relatively few Medicaid-insured children, so the findings may underrepresent clinicians in higher-Medicaid settings, where coverage and prior-authorization issues can play out differently,” said King. “That’s something we want to address directly in future work.” While nearly all respondents reported routinely managing the core aspects of asthma treatment, including action plans, only 63% reported providing SMART-tailored action plans, which emerged as a key barrier across different care settings. Two findings in particular caught the investigators’ attention: the relative absence of SMART-specific asthma action plans and the real difficulty of helping families let go of trusted SABA rescue inhalers, King said. “The pediatric context, where care is shared across parents, schools, and other caregivers, added a layer that adult studies simply do not capture.” Offering her perspective on the study but involved in it, Santina J. Wheat, MD, MPH, physician in the Division of Family Medicine at Northwestern Medicine Delnor Hospital in Geneva, noted that while SMART is easier to use for families because there are fewer medications to worry about, the biggest barrier remains insurance approval. “When SMART is used correctly, families run out of the medication more quickly than insurance will pay for it,” she told Medscape Medical News.Even when insurance does cover it, there are often prior authorizations associated with the medications that delay families in being able to get the medications, she said. Standard coverage authorizations for the SMART inhalers would be helpful, said Wheat. “Additionally, we need the support of schools — training and education may be needed for the school nurses to support the children with these treatment plans.” Single fixes will not do it, King agreed. “It takes a coordinated bundle.” On the clinician side, practical, hands-on support like practice facilitation, feedback, and brief educational outreach will help move people from belief into routine use. On the system side, building SMART-specific asthma action plans directly into the electronic health records removes a recurring point of friction. “And because pediatric asthma care is distributed across families and schools, caregiver-facing education and clear school communication tools are essential to help everyone move away from automatic albuterol use.” Fortunately, the appetite for change is already there. “Clinicians are not skeptical of the evidence,” King said. “This is an implementation challenge, not a debate about whether SMART works, and that is a hopeful place to start, because implementation problems are solvable with the right tools and support.” Partnerships with professional societies are essential to moving this into national practice, King added. “SMART sits at the intersection of primary care, allergy, and pulmonology, so collaboration across those communities matters.” This research was supported by the American Lung Association, the National Heart, Lung, and Blood Institute, the National Center for Advancing Translational Sciences, the Doris Duke Charitable Foundation, and the Children’s Discovery Institute, a collaboration between the St. Louis Children’s Hospital, its foundation, and WashU Medicine. King reported receiving funding from the National Institutes of Health (NIH), consulting for Evernorth, and royalties from UpToDate. Co-author James G. Krings disclosed funding from the NIH, the American Lung Association, the Patient-Centered Outcomes Research Institute, and the Doris Duke Charitable Foundation, and consulting fees or honoraria from multiple pharmaceutical companies, including, among others, AstraZeneca, GSK, Sanofi-Regeneron (manufacturers of SMART inhalers), Aerogen, and Genentech/Roche. Aimes S. James reported receiving funding from the NIH and the Barnes-Jewish Hospital Foundation. All other authors reported having no relevant financial disclosures. Wheat reported having no conflicts of interest.