Barriers to Implementing SMART for Asthma in Pediatric Primary Care

OBJECTIVES: To characterize awareness, use, and perceived barriers to implementing single maintenance and reliever therapy (SMART) in primary care for children aged 5 years or older, hypothesizing high clinician awareness but limited use due to multilevel clinician-, system-, and caregiver barriers. METHODS: We conducted a sequential explanatory mixed-methods study among pediatric primary care clinicians within a practice-based research network. Clinicians completed a survey assessing SMART awareness, prescribing practices, and perceived barriers, guided by the Consolidated Framework for Implementation Research (CFIR) 2.0. Semistructured interviews were conducted with purposively sampled clinicians to explore factors influencing SMART implementation. Qualitative data were analyzed using an inductive-deductive approach and mapped to CFIR 2.0 constructs. RESULTS: Fifty-two clinicians (27.5%) completed the survey, and 24 completed interviews. Awareness of SMART was universal, but use remained limited among eligible pediatric patients, particularly younger children. Clinicians viewed SMART as effective and guideline-concordant but described multilevel barriers to routine implementation. Qualitative analysis identified 3 themes: (1) SMART is clinically advantageous but challenging to operationalize; (2) system-level and workflow barriers, including insurance coverage and prior authorization requirements, constrain adoption; and (3) caregiver resistance impedes deimplementation of short-acting β-agonists. Absence of SMART-specific asthma action plans emerged as a key barrier across care settings. CONCLUSION: Pediatric primary care clinicians endorse SMART therapy but face persistent clinician-, system-, and caregiver-level barriers to its implementation and to the deimplementation of short-acting β-agonists. Implementation strategies incorporating practice facilitation, audit and feedback, and electronic health record-generated SMART-specific asthma action plans may support more consistent uptake of pediatric guideline-concordant asthma care.