Adoption and Implementation of Maintenance and Reliever Therapy for Adults with Moderate to Severe Asthma

Abstract

Background:

The use of single combination inhaled corticosteroid (ICS) and long-acting bronchodilator for maintenance and relief (MART) significantly reduces asthma exacerbations and has been incorporated into asthma guidelines since December 2020, but there is limited data regarding the implementation of this approach to asthma management.

Objective:

Determine how often MART was prescribed to patients with moderate to severe asthma being seen at subspecialty pulmonary and allergy practices at an academic health care system, and the patient and clinician characteristics associated with the use of MART.

Methods:

We conducted a retrospective cross-sectional study of the EMR of an academic health care system in the Northeastern US between January 2021 and October 2023. Patient demographic and clinician data was collected, and MART recommendation was confirmed by chart review. We assessed the relationships between patient demographics, clinician characteristics, and MART recommendation.

Results:

Of 2,016 patients reviewed, 293 (14.5%) were recommended MART, with 255 (87%) concurrently prescribed short acting bronchodilators. Patients on ICS/formoterol at baseline were significantly more likely to be recommended MART, while older patients and those on Medicare were significantly less likely to be recommended MART. Twenty-two (44%) of 50 clinicians did not recommend MART ever and only three clinicians recommended MART to 30–60% of their patients. Clinicians who were part of the asthma group and those with less than 16 years in practice were significantly more likely to recommend MART.

Conclusion:

Among academic subspecialty clinicians, there has been limited implementation of MART, with a small number of clinicians adopting MART routinely and over 40% of clinicians not recommending it.

Introduction

Asthma is the most common chronic inflammatory lung disease in the United States, affecting over 20 million people over the age of 18 in the United States. Asthma causes 8 million asthma exacerbations annually, resulting in over 700,000 ED visits and over 67,000 hospital admissions.¹ For years, the standard stepwise approach to pharmacologic therapy in asthma focused on as needed short acting bronchodilator (SABA) inhalers (i.e., albuterol) for symptom relief, with the addition of daily maintenance inhalers such as inhaled corticosteroids (ICS) and long-acting bronchodilators (LABA) if asthma symptoms require it for control.

As of December 2020, both the National Asthma Education and Prevention Program (NAEPP) guidelines and Global Initiative for Asthma (GINA) recommendations transitioned from the maintenance/reliever approach to the use of combination ICS-rapid acting LABA inhaler (formoterol) for both maintenance and as needed symptom relief, or MART, specifically for patients with moderate or severe asthma.^2,3 MART reduces asthma exacerbations by providing additional anti-inflammatory therapy when airway inflammation is acutely worsening. Randomized controlled trials have shown that MART leads to a significant reduction in asthma exacerbations, defined as systemic corticosteroid use, hospitalizations, or Emergency Department visits,^4,5,6,7 along with decreased need for reliever inhaler therapy.^8,9 Additionally, the use of a single inhaler with MART improves medication adherence¹⁰ and is a patient-centered treatment with high acceptability and possible cost-savings.¹¹

Despite the proven benefit of MART in clinical trials, the data that is available suggests that it is not widely used in the real-world setting. Survey data from over 1,800 physicians in six countries (not including the United States) shows that 83% of physicians endorsed knowledge of MART, but the proportion of combination ICS-LABA prescribed as MART ranged from 33–47%.¹² Among physicians prescribing MART, 91% reported that they concurrently prescribe a SABA as a reliever inhaler with MART due to patient perceived safety, patient familiarity with SABAs as relievers, and patient convenience,¹² a practice which limits the efficacy of MART as patients may prefer albuterol and not use the ICS containing reliever.¹³ Past research has suggested it takes an average of 17 years for research evidence to reach clinical practice,^14,15,16 making it difficult to keep up with rapidly-evolving evidence-based guidelines and new technologies. This highlights how important it is to understand the determinants of MART implementation and how to overcome barriers to improve its adoption.

There has been limited data to describe adoption of MART in clinical practice following the update in asthma management guidelines, with no data on the implementation of MART using objective administrative or electronic medical record (EMR) data in the United States. In this study, we aimed to determine the implementation of MART among eligible patients within subspecialty pulmonary and allergy practices at an academic health care system in the Northeastern US. Furthermore, we aimed to determine patient and clinician characteristics associated with MART recommendation to help identify potential barriers to MART adoption and areas for improvement in the implementation of asthma management guidelines, to ultimately lead to improved asthma control, better lung function, and better patient centered care.

Methods

This study was determined to be exempt by the University Investigational Review Board (2000034811). We conducted a search of the electronic medical record (EMR), EPIC, to identify patients who were eligible for MART in an academic health care system in the Northeastern US. Inclusion criteria for the study included: 1) ICD-10 code diagnosis of asthma, 2) at least one visit to a pulmonary or allergy office between January 2021 (after the NAEPP guidelines were updated) and October 2023, and 3) active prescription for a maintenance ICS-containing inhaler at the time of the clinic visit, which would qualify the patient as having at least moderate asthma (Step 3 or above according to GINA management guidelines).¹⁷ Patients with concurrent pulmonary diagnoses (i.e. chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, interstitial lung disease, eosinophilic granulomatosis with polyangiitis, sarcoidosis, or bronchiolitis obliterans syndrome) and patients with a history of organ transplantation were excluded from the study. Patient demographic and clinical information including age, sex, ethnicity, race, body mass index (BMI), smoking status, primary insurance coverage, asthma medication regimen, and comorbidities were obtained from the electronic medical record from the patient’s first visit within the data capture time frame. Comorbidities collected for this study included diabetes, hypertension, cardiovascular disease, cancer, stroke, chronic kidney disease, depression, anxiety, HIV/AIDS, gastroesophageal reflux, allergic rhinitis, and atopic dermatitis.

Chart review was conducted of the patients identified by the EMR data and analytics search report to confirm the eligibility criteria for inclusion into the study were met. At the time the study was conducted, the EMR did not have a pre-populated mechanism to prescribe ICS-formoterol for maintenance and relief. Prior to initiating the study, clinicians were surveyed regarding their documentation of MART prescription. Clinicians confirmed that if they intended for the patient to initiate MART, they did one or more of the following things: 1) documented that the patient would be using either budesonide-formoterol or mometasone-formoterol for maintenance and reliever purposes in the assessment and plan, 2) included the term (S)MART within the plan or 3) wrote instructions for (S)MART within the patient instructions. Therefore, pulmonary and allergy clinician notes and patient instructions were reviewed for each visit to determine if the patient was recommended to use ICS-formoterol as MART, with discussion and agreement on the treatment plan from the patient (which will be referred to as “MART recommendation” throughout the rest of this manuscript). On the date of MART recommendation, the patient’s baseline maintenance inhaler was assessed prior to transitioning to MART (either ICS-formoterol or not ICS-formoterol), and the patient’s SABA prescription was reviewed. A patient was listed as having concomitant SABA prescription if any type of albuterol or levalbuterol (via inhaler or nebulizer) was prescribed at the time the patient was recommended MART or if provider notes stated it in the plan.

For purposes of analysis, clinicians were identified by type of provider (either physician or advanced practice provider (APP)), clinician subspecialty (pulmonology or allergy), whether or not they were a member of the Center for Asthma and Airway Disease group (CAAD, a group within pulmonary medicine in which clinicians primarily see patients with asthma), and the number of years the clinician had been in practice. For physicians, the number of years in practice was the number of years since earning their MD and for APPs, the number of years in practice was the number of years since earning their practitioner credentialing.

Statistical Analysis

Descriptive statistics were used to assess the proportion of patients recommended MART of those who were eligible to receive MART, the proportion of patients concurrently prescribed SABA with MART, and the frequency that each clinician recommended MART, which was defined as the number of times the clinician recommended MART divided by the number of patients with asthma seen by the clinician during the study time period. Multivariable logistic regression was conducted to assess the relationship between a priori identified patient demographic data (age, gender, race, ethnicity, smoking status, BMI, number of comorbidities, insurance type, and baseline maintenance inhaler) and recommendation of MART. The patient’s primary insurance was classified as private, Medicare, or Medicaid; participants were described as having 0, 1, 2, or 3+ comorbidities; BMI was coded as obese (BMI of 30 and above) and non-obese (BMI below 30); and smoking status was coded as nonsmoker, current smoker, or former smoker. The multi-level regression model was nested by clinician to account for the variance in being seen by that provider.

A Spearman’s Rank correlation coefficient was calculated to determine the strength of correlation between number of patients with asthma seen and number of MART recommendations. A Wilcoxon Rank Sum test was performed to assess the differences in frequency of MART recommendation between CAAD clinicians who focus on asthma and non CAAD clinicians, physicians and APPs, pulmonologists and allergists, and clinicians in practice for 16 years or less compared to more than 16 years in practice. Sixteen years was selected as this was the median number of years that clinicians were in practice.

Results

There were 2,866 patients identified for chart review. After chart review was performed, 850 patients were determined to be ineligible, resulting in a total of 2,016 patients with moderate to severe asthma being included in the analysis (Figure 1). Patients who were determined to be ineligible if they did not have a diagnosis of asthma (N=56), had no current prescription of ICS or ICS-LABA during the qualifying time period (N=380), had excluding pulmonary diagnoses (N=401), or had a history of organ transplantation (N=9). There were 50 clinicians identified within the sample who had at least one patient visit for asthma, with 33 clinicians seeing more than 5 patients with asthma during the study.

Figure 1: Study Flow Chart.

Flow chart of patients included within the study, showing percentage of patients with moderate to severe asthma recommended Maintenance and Reliever Therapy (MART).

Abbreviations: ICS - Inhaled corticosteroid; LABA – Long-acting beta agonist; COPD- Chronic obstructive pulmonary disease; ILD – Interstitial lung disease; CF – Cystic Fibrosis; SABA – Short-acting beta agonist.

Patient and Clinician Demographics

The mean age of patients was 48.2 years (SD 15.7 years), with 75% of patients being female. Over 20% identified as Black or African American, 23% identified as Latinx or Hispanic and more than half (51.5%) identified as White. The majority (69.6%) of patients were nonsmokers. The mean BMI of patients was 31.9 kg/m² (SD 8.5 kg/m²). Most patients (62.7%) had private primary insurance, 26.6% of patients identified Medicaid as their primary insurance, and 9.3% identified Medicare as their primary insurance. Finally, 880 patients (43.7%) were on ICS-formoterol as a baseline maintenance inhaler, whereas 1,136 patients were on alternative ICS or ICS-combination inhalers for baseline maintenance. Fifteen percent (N=307) of patients were prescribed biologic therapy for asthma. The demographic characteristics of patients on MART and patients not on MART can be found in Table 1.

Table 1.

Patient Demographic Characteristics (N=2016)

	Overall	On MART (N=293)	Not on MART (N=1,723)
Age, mean (SD)	48.2 (15.7)	43.2 (15.5)	49.04 (15.5)
Sex, N (%)
Male	505 (25%)	74 (25.3%)	431 (25.0%)
Female	1511 (75%)	219 (75.7%)	1,292 (75.0%)
Ethnicity, N (%)
Hispanic or Latina/o/x	467 (23%)	75 (25.6%)	392 (22.8%)
Not Hispanic or Latina/o/x	1497 (74%)	214 (73.0%)	1,282 (74.4%)
Missing	53 (2.6%)	4 (1.4%)	49 (2.8%)
Race, N (%)
American Indian or Native American	18 (0.9%)	2 (0.7%)	16 (0.9%)
Asian	67 (3.3%)	13 (4.4%)	54 (3.1%)
Black or African American	393 (19.5%)	57 (19.5%)	336 (19.5%)
White	1218 (60.4%)	176 (60.1%)	1,042 (60.5%)
Other	8 (0.4%)	0	8 (0.5%)
Missing	312 (15.5%)	45 (15.4%)	267 (15.5%)
BMI
Mean (SD)	31.9 (8.5)	31.2 (8.2%)	32.0 (8.5%)
Non-obese, N (%)	950 (47%)	152 (51.9%)	798 (46.3%)
Obese, N (%)	1032 (51%)	131 (44.7%)	901 (52.2%)
Missing, N (%)	34 (2%)	10 (3.4%)	24 (1.4%)
Smoking status, N (%)
Nonsmoker	1404 (69.6%)	217 (74.1%)	1,187 (69%)
Current	105 (5.2%)	20 (6.8%)	85 (4.9%)
Former	497 (24.7%)	56 (19.1%)	441 (25.6%)
Missing	10 (0.5%)	0	10 (0.6%)
Number of comorbidities, N(%)
0	411 (20.4%)	81 (27.7%)	330 (19.1%)
1	411 (20.4%)	72 (24.6%)	339 (19.7%)
2	311 (15.4%)	41 (14%)	270 (15.7%)
3+	873 (43.3%)	99 (33.8%)	774 (44.9%)
Missing	10 (0.5%)	0	10 (0.6%)
Primary Insurance Type, N(%)
Medicare	187 (9.3%)	9 (3.1%)	178 (10.3%)
Medicaid	537 (26.6%)	80 (27.3%)	457 (26.5%)
Private	1264 (62.7%)	194 (66.2%)	1070 (62.1%)
Missing/ No Insurance	28 (1.4%)	10 (3.4%)	18 (1.0%)
Baseline controller inhaler, N(%)
Budesonide/formoterol or mometasone/formoterol	880 (43.7%)	253 (86.4%)	627 (36.4%)
Other controller	1136 (56.3%)	40 (13.7%)	1,096 (63.6%)
Biologic therapy for asthma, N(%)	307 (15.2%)	28 (9.5%)	279 (16.2%)

Among the 50 clinicians included in the analysis, 42 were pulmonologists and 8 were allergists. There were 46 physicians within the sample and four APPs. All physicians included within the study were attending physicians. Clinicians saw a range of 1 to 282 patients with asthma. Eight pulmonologists who were identified as part of CAAD and primarily see patients with asthma. Clinicians were in practice for a median of 16.5 years (interquartile range: 11–25 years).

Prescription of MART and SABA

Only 14.5% (293 patients) were recommended ICS-formoterol as MART, indicating low adoption. Most patients recommended MART were concurrently prescribed a SABA (87%, N=255), leading to uncertainty regarding what these patients primarily used as reliever therapy; if they use their SABA, this may decrease the efficacy of MART (Figure 1). Only 28.8% (N=253) of patients prescribed ICS-formoterol as a baseline maintenance inhaler (N=880) were recommended MART. Additionally, 23 patients (1.1%) were transitioned to use of either budesonide-formoterol or mometasone-formoterol only as a reliever. Together, these results suggest that the majority of patients were not receiving guideline concordant care for asthma.

Multivariable regression model

In looking at patient factors impacting adoption of MART, patients on ICS-formoterol as a baseline maintenance inhaler were significantly more likely to be recommended MART therapy (OR: 12.9, 95% CI: 8.8 – 19.0) when controlling for other covariates. Baseline maintenance therapy of ICS-formoterol was the largest determinant of MART adoption, suggesting it is easier to transition people on ICS-formoterol at baseline to MART therapy. Patients on Medicare were significantly less likely to be recommended MART than patients with private insurance (OR: 0.42, 95% CI: 0.19 – 0.92). Finally, older patients were significantly less likely to be recommended MART than younger patients (OR: 0.98, 95% CI: 0.97 – 0.99) (Table 2).

Table 2.

Multivariate analysis nested by clinician (N=1,910)

Variable	Odds Ratio [Confidence Interval]	P-value
Age	0.98 [0.97 – 0.99]	0.03*
Smoking status
Nonsmoker	Reference
Current	0.76 [0.39 – 1.48]	0.41
Former	0.78 [0.53– 1.15]	0.21
Gender
Male	Reference
Female	0.92 [0.64 – 1.32]	0.66
Race
White or Hispanic with no race identified	Reference
American Indian or Native American	1.38 [0.24 – 7.97]	0.72
Asian	0.93 [0.39 – 2.19]	0.87
Black or African American	0.95 [0.63 – 1.46]	0.83
Other Race	1.41 [0.64 – 3.07]	0.39
Ethnicity
Not Hispanic/Latinx	Reference
Hispanic/Latinx	1.18 [0.80 – 1.76]	0.40
BMI Class
Non-obese	Reference
Obese	0.82 [0.59 – 1.13]	0.22
Number of comorbidities
0	Reference
1	1.22 [0.77 – 1.94]	0.39
2	0.81 [0.48 – 1.34]	0.41
3+	0.83 [0.53 – 1.28]	0.40
Insurance type
Private	Reference
Medicare	0.42 [0.19 – 0.92]	0.03*
Medicaid	0.71 [0.48 – 1.04]	0.08
Baseline controller inhaler
Not ICS/formoterol	Reference
ICS/formoterol	12.9 [8.8 – 19.0]	<0.001*
Biologic Therapy for Asthma	0.63 [0.39–1.03]	0.06

Frequency of MART Recommendation by Clinician

Forty-four percent (N=22) of clinicians had not adopted MART for patients with moderate to severe asthma with the majority of clinicians (94%, N=47) recommending MART 30% or less of the time. Only two clinicians recommended MART to more than 40% of their patients with asthma, indicating a significant lack of adoption of MART among most clinicians. To examine the relationship between number of patients seen in asthma clinic by clinicians and MART recommendation, we conducted a Spearman Rank correlation test and found that clinicians who saw more patients with asthma were more likely to prescribe MART (Spearman rank correlation coefficient of 0.84, p = <0.001) (Figure 2).

Figure 2: Number of MART Recommendations compared to Number of Patients Seen.

A comparison of the number of MART recommendations made by clinician versus the number of patients with moderate to severe asthma seen by the clinician. Triangles indicate clinicians who were part of the Center for Asthma and Airway Disease asthma group, who primarily see patients with asthma. Circles indicate all other clinicians. Spearman rank coefficient was calculated.

Characteristics of Clinicians Prescribing MART

There was no statistical difference in adoption of MART between physicians and APPs or between pulmonologists and allergists. Clinicians who were part of CAAD had significantly higher frequency of MART recommendation (Median: 19.8%, IQR: 7.9–37.5%) than clinicians not part of CAAD, (Median: 0%, IQR: 0–9.5%) (p = 0.002), showing that clinicians who were part of an asthma subspecialty group were more likely to recommend MART. Clinicians in practice for 16 years or less had higher frequency of MART recommendation (Median: 8.3%, IQR: 0–20.6%) than clinicians in practice for over 16 years (Median: 0%, IQR: 0–9%), with the result approaching statistical significance (p = 0.05), Figure 3.

Figure 3: Characteristics of Clinicians Recommending SMART, N=50.

Boxplots showing frequency of MART recommendations between clinicians who were part of the Center for Asthma and Airway Disease asthma group versus other clinicians, physicians versus advanced practice providers, pulmonologists versus allergists, and clinicians who were in practice for ≤ 16 years compared to clinicians in practice > 16 years. A Wilcoxon rank sum test was used to compare groups.

Discussion

This is the first study to examine the implementation of MART in pulmonary and allergy practices at an academic health system in the U.S using EMR data. Our study showed limited implementation of MART among patients with moderate to severe asthma, with less than 15% of patients who were eligible for MART being recommended MART and 87% of patients receiving concurrent SABA prescription. We also showed limited adoption of MART as over 40% of academic clinicians had not adopted MART, with only two clinicians recommending MART more than 40% of the time for their patients with moderate to severe asthma. Taken together, our findings suggest that adoption of MART has been slow to date, and greater efforts are needed to improve guideline-based MART implementation.

Prior survey data collected outside of the United States similarly suggested low levels of MART implementation and high rates of concurrent SABA prescription.¹² Recent data from New Zealand showed a marked increase in budesonide-formoterol prescribing with a decline in the prescription of alternative ICS-LABA inhalers and SABAs following the publication of 2020 New Zealand guidelines promoting the use of MART, suggesting a shift in prescription patterns to ICS-formoterol.¹⁸ Unfortunately, this study was limited as the authors were unable to determine the proportion of budesonide-formoterol prescriptions which were prescribed as MART. In contrast the study herein relied on direct/manual chart review of physician notes and reconciled medication lists in the EMR. Even with this robust approach, low percentages of patients that were eligible were recommended MART. This highlights challenges facing studies regarding the adoption of MART as there has been no consistent way in EMRs to prescribe MART, and chart review to determine prescription of MART is time intensive.

Several factors may make implementation of MART in the United States more challenging, including lack of approval from the US Food and Drug Administration (FDA) of ICS-formoterol as reliever therapy¹⁹ and poor coverage of ICS-formoterol by many US insurance formularies, who preferentially cover alternative ICS-LABA inhalers, which are incompatible with implementation of MART.²⁰ Finally, several US insurers will only cover the cost of a 30-day supply of medication, making it more challenging for patients on MART who may require more than one inhaler per month,¹⁹ and potentially making them more likely to use albuterol as a reliever. Our study found that patients on Medicare were significantly less likely to be recommended MART, which may have been secondary to a lack of coverage of ICS-formoterol as a controller and reliever on Medicare coverage plans or lower likelihood for clinicians to implement MART among older patients who would be eligible for Medicare.

Regarding patient-specific factors, we found that MART was significantly more likely to be adopted in patients with asthma who were on baseline maintenance ICS-formoterol. In addition to insurance formulary coverage, we suspect patient preference in inhaler regimen may contribute to this finding. Transitioning to MART from ICS-formoterol maintenance is more straightforward than transitioning from a non-ICS-formoterol maintenance regimen to ICS-formoterol for MART, particularly if patients are doing well with their current regimen.²⁰ Over 70% of patients prescribed ICS-formoterol for maintenance were not recommended MART. Barriers contributing to MART prescription in this group may include reluctance of clinicians to adopt MART, patient preference to use albuterol over ICS-formoterol as a reliever,¹² and/or concerns that insurance will not cover more than one ICS-formoterol inhaler per month. Within our chart review, clinician recommendation for MART with patient preference for asthma regimen other than MART was not frequently documented. Finally, MART was less likely to be adopted in older patients. Clinicians may be wary of using excess formoterol in older patients due to theoretical side effects of excess LABA use (i.e. cardiac side effects such as elevated blood pressure or tachycardia).²¹ Notably, no difference in risk of death or non-fatal serious adverse events have been found to date in patents taking combined ICS-formoterol versus ICS alone.²²

We believe there are several factors limiting the adoption of MART that was seen in academic clinicians in this study. Our prior research showed that over 90% of pulmonary clinicians knew MART was part of updated asthma management guidelines, suggesting that factors limiting adoption extend beyond knowledge.²³ The COM-B model of behavior change can help to explain challenges in clinician adoption of MART. The model suggests that capability or the capacity to engage including necessary knowledge and skills, motivation, and opportunity or factors outside of the individual contribute to the ability to make behavior change.²⁴ While clinicians may have knowledge of MART, they may not have the time, motivation, or external support to educate patients on how to transition to MART or to manage challenges with cost and insurance formulary coverage of MART.^23,25 We found that clinicians who were part of the asthma group were more likely to adopt MART. The asthma group has a dedicated nurse and pharmacist, which may make challenges with patient education and pharmaceutical coverage of MART easier to navigate for clinicians who are part of the asthma group. Clinicians with fewer years in practice recommended MART more frequently than clinicians in practice for over 16 years, with the result approaching statistical significance. More experienced clinicians may be more likely to choose treatment regimens which have been successful in the past and be less likely to adopt new treatment paradigms.

There were limitations to our study. For feasibility purposes we focused on a single academic medical center and two specialty practices (pulmonary and allergy) that manage the most patients with asthma. Specialists within these fields are likely the most up to date on current asthma management guidelines. We anticipate that adoption of MART in primary care or community practice settings is similar if not less than in this study. Within the study, 17 clinicians saw fewer than 5 patients with asthma in the study time frame. This study was conducted at a quaternary care center where many pulmonologists focus on a subspecialty of pulmonary disease. This study focused on patients with asthma and excluded patients with more than one pulmonary diagnosis. We did not include a measure of asthma control as we did not have longitudinal data available on asthma control before and after MART recommendation. Many of the patients included within the study were established patients prior to guideline adoption. Implementation of a new treatment may be more of a challenge in this patient population due to reluctance to change therapy. We did not focus on mild asthma within this study as those patients are not typically candidates for MART and are less likely to be referred to specialty practices. We acknowledge that patients with mild asthma do benefit from anti-inflammatory reliever therapy and that implementation of anti-inflammatory reliever therapy should be assessed in a future study. Our assessment of MART recommendation with discussion and agreement on the treatment plan from the patient was contingent on clinician documentation of MART within the assessment and plan and/or in the patient instructions. Clinicians within the study stated that this was how they documented recommendation for MART as the EMR did not allow for a pre-populated mechanism to prescribe ICS-formoterol for maintenance and relief. We did not systematically collect how often MART was recommended by the provider but declined by the patient, but overall found this was infrequently documented. Finally, our academic center may not be representative of other medical centers throughout the US. Most patients within our study had some form of public or private insurance. Patients who lack insurance coverage would likely have lower adoption of MART given the cost of inhalers and lack of universal health care coverage.

Future studies should identify strategies to improve MART implementation. To improve adoption of MART, we anticipate that these strategies will need to address clinicians, patients, and health systems level barriers to medication access for patients. Potential strategies include clinician education and bolstering clinician support to adopt MART through the development of clinician decision support tools and better integration of outpatient pharmacy support; the development of patient education material and additional nursing support for education; and addressing policies to reduce cost and improve insurance coverage for ICS-formoterol as maintenance and reliever therapy. Additionally, the implementation of alternative anti-inflammatory reliever (AIR) therapies such as albuterol/budesonide (recently approved FDA reliever for asthma)²⁶ and patient activated reliever triggered inhaled corticosteroid (PARTICs)²⁷ must be investigated as these approaches are similar to MART as they aim to increase anti-inflammatory therapy when airway inflammation is acutely worsening and may be preferable for some patients and better covered by some insurance formularies.²⁸

In conclusion, there has been limited adoption of MART in the United States despite robust clinical trial data supporting the use of MART for moderate to severe asthma and the integration of MART in asthma practice guidelines. This study highlights that few subspecialty clinicians are routinely adopting MART for patients with moderate to severe asthma in an academic health setting. Patient, clinician, and health systems factors are contributing to the low adoption of MART and further research will need to be done to improve how to best improve implementation and adoption of MART.

Table 1b.

Clinician Characteristics (N= 50)

	Overall
Type of clinician, N (%)
Physician	46 (92%)
Nurse Practitioner	4 (8%)
Specialty, N (%)
Pulmonology	42 (84%)
Allergy and Immunology	8 (16%)
Asthma group (CAAD) member, N(%)	8 (16%)
Non asthma group member	42 (84%)
Years in Practice, median (IQR)	16.5 (IQR: 11–25)

Abbreviations:

AIR

Anti-inflammatory reliever

ACT

Asthma Control Test

BMI

Body Mass Index

EMR

Electronic Medical Record

FDA

Food and Drug Administration

GINA

Global Initiative for Asthma

ICS

Inhaled corticosteroids

LABA

Long-acting beta agonist

MART

Maintenance and Reliver Therapy, also known as SMART

NAEPP

National Asthma Education and Prevention Program

SABA

Short acting beta agonist

SD

Standard deviation

CAAD

Center for Asthma and Airway Disease