312 - An Examination of Single Maintenance and Reliever Therapy (SMART) Implementation in Pediatric Practice

Publication Number: 2301.312

Michelle Trivedi, UMass Memorial, Worcester, MA, United States; Michelle Spano, University of Massachusetts Chan Medical School, Worcester, MA, United States; Deicy Mejia Agudelo, Umass Chan Medical School, Worcester, MA, United States; Stephanie Simms, University of Massachusetts Medical School, Mount Pleasant, SC, United States; Christine Frisard, University of Massachusetts Chan Medical School, Worcester, MA, United States; Hannah Seay, MassGeneral Brigham for Children, Boston, MA, United States; Elika Eshghi, University of Massachusetts Medical School, Worcester, MA, United States; Grace W. Ryan, University of Massachusetts Chan Medical School, Worcester, MA, United States; Melissa Goulding, University of Massachusetts Medical School, Worcester, MA, United States; Stephenie Lemon, UMass Chan Medical School, Worcester, MA, United States; Nancy Byatt, UMass Chan Medical School/UMass Memorial Health, Shrewsbury, MA, United States; Sybil L. Crawford, University of Massachusetts Medical School, Worcester, MA, United States; Lori Pbert, University of Massachusetts Medical School, Harvard, MA, United States

Background: Since 2020, Single Maintenance and Reliever Therapy (SMART) has been the guideline-recommended treatment for children aged 4 years and older with uncontrolled asthma. SMART uses a single inhaler containing a combination inhaled corticosteroid-formoterol for both daily maintenance and quick symptom relief. Despite known efficacy, there is limited knowledge on SMART implementation within pediatric clinical practice.

Objective: To examine SMART prescribing patterns, identify key implementation facilitators and barriers, and explore strategies to support its uptake among primary care pediatricians.

Design/Methods: From May to October 2025, we invited 102 pediatric primary care providers in central Massachusetts to complete a survey on SMART use. The survey was grounded in the Consolidated Framework for Implementation Research, and results were analyzed using descriptive statistics. The UMass Chan Institutional Review Board reviewed and approved study procedures.

Results: A total of 76 pediatric primary care providers (75% response rate), working in 14 urban practices (1 academic, 13 community-based) completed the survey. When asked how often they prescribe SMART for patients with uncontrolled asthma, 38% report "rarely" or "never", 34% report "sometimes", and 28% report "often" or "always" (Figure 1). Providers identified several advantages of SMART including a simplified regimen, potential to reduce exacerbations, and opportunities for shared decision-making. No providers cited a lack of evidence for SMART as a barrier to adoption. Instead, providers highlighted implementation challenges such as unclear guidance on how and when to initiate SMART, concerns that patients might continue albuterol or nebulizer use, challenges with use across settings (e.g., school/urgent care) and insurance coverage issues. Providers emphasized the need for training on SMART use, clinical decision support for patient selection, educational materials for counseling, and improved communication with schools to align care plans (Table 1).

Conclusion(s): SMART adoption was low and variable in pediatric practice, underscoring the need for targeted strategies to support broader implementation of SMART. Providers highlighted key challenges related to implementation (prescribing logistics, workflow integration, albuterol reliance and coordination across care settings) rather than skepticism regarding SMART itself. Targeted strategies to understand and overcome these obstacles could support a transition to guideline-recommended SMART and ultimately improve pediatric asthma management.

Figure 1. Provider Prescribing Rates of SMART (n= 76)


Table 1. Provider-reported Facilitators and Barriers to SMART Implementation (n=76)