Get SMART? Understanding Pediatric Pulmonologists' Perspectives on Implementation of SMART

To the Editor,

1. Introduction

Pediatric asthma management experienced a paradigm shift in 2020 with the Global Initiative for Asthma (GINA) recommending single maintenance and reliever therapy (SMART) for those 6 years and older with mild‐moderate asthma symptoms [1]. Inhaled corticosteroid (ICS) combined with a β‐agonist was superior to β‐agonist rescue therapy alone at reducing risk of severe asthma exacerbation or death in older children and adults [2].

The National Heart Lung and Blood Institute (NHLBI) administers and coordinates the National Asthma Education and Prevention Program (NAEPP). In 2020, the NAEPP recommended SMART usage for pediatric patients with persistent asthma ages 4 and older [3].

While the data support SMART in patients ages 12 and up [4], SMART has not been evaluated in younger children except in post‐hoc analyses. Clinicians have also identified difficulties in implementation; obstacles include patient adherence, insurance coverage, and provider awareness and understanding [5]. We sought to understand the current pediatric pulmonary provider experiences using cross‐sectional survey data to help inform optimal pediatric asthma management.

2. Methods

The study was approved by the Seattle Children's Institutional Review Board. The anonymous survey was distributed via REDCap to the Peds‐Lung Listerv, an international group “for professionals with an interest in Paediatric Respiratory Medicine” and is currently comprised of 1631 subscribers. The survey was voluntary and adhered to ethical standards approved by Seattle Children's IRB (IRB ID: STUDY00005488). All respondents that participated in the study provided informed consent prior to taking the survey. The survey was only offered in English (Supporting Information: Figure S1). Survey responses were collected from 6/11/2025 to 7/15/2025 with three reminders sent out to the listerv during data collection. Once data collection was complete, responses were compiled and analyzed with Microsoft Excel Version 16.66.1 and R version 4.0.1.1. Descriptive statistics are presented as number (%) for categorical variables. For initial group comparisons, we used Fisher's exact test, Kruskal‐Wallis test, or Jonckheere‐Terpstra Test as appropriate.

3. Results

We received 137 responses, 135 of which were fully completed. Of the 135 respondents, 51% identified as male and 44% identified as female. A smaller portion comprising 4% of the group preferred not to disclose gender, and 1% identified as gender non‐binary or genderqueer. The racial composition of participants was 72% identifying as White, 10% identifying as Asian, 9% as another race not listed, and 3% as multi‐racial with 6% preferring not to disclose. Of those surveyed, 75% of participants practice within the US and 25% practice internationally.

Years in practice varied amongst pediatric pulmonologists in the survey group with 22% listing time in practice less than 5 years, 20% having practiced for 5–10 years, 30% having practiced for 10–20 years, and 28% having practiced for more than 20 years. Pediatric providers from academic medical centers represented 78% of individuals in the survey. The rest of the study population was distributed with 6% in private practice, 15% in a hybrid setting, and 1% in a setting other than academic or private practice.

Most respondents felt comfortable (28%) or very comfortable (53%) prescribing SMART; 5% felt uncomfortable and 1% felt very uncomfortable. Practice location significantly influenced comfort levels, with US pulmonologists expressing greater comfort with prescribing SMART than international pulmonologists (p = 0.006). Physicians in academic settings were significantly more comfortable with SMART than physicians in hybrid or private settings (p < 0.001). Pulmonologists with fewer than 10 years in practice exhibited the most comfort with SMART (Figure 1). While pulmonologists with greater than 20 years of experience indicated significantly less comfort with SMART (p = 0.034). Race and gender did not significantly impact prescribing comfortability.

FIGURE 1.

Level of comfort prescribing SMART based on clinician's time in practice. [Color figure can be viewed at wileyonlinelibrary.com]

The survey also assessed guideline usage for prescribing SMART (Figure 2A,B). Based on survey response, 56% of pediatric pulmonologists used both GINA and NHLBI, 33% used GINA guidelines alone, 4% used NHLBI guidelines, and 5% did not endorse utilizing SMART. The minimum age of prescribing SMART was also surveyed, which found that 40% of prescribers use the minimum age of 6 years old, 34% use the minimum age of 4 years old, 8% use no age limit, and 5% do not utilize SMART. Practice location had a significant influence on guideline usage, with US pulmonologists using both GINA and NHLBI guidelines whereas international pulmonologists used GINA more exclusively (p = 0.024). Other factors did not demonstrate a significant effect of guideline usage.

FIGURE 2.

(A) Percentages of pediatric pulmonologists that use each asthma guideline for management of mild asthma. (B) The number of clinicians that indicate using designated age cut‐offs for prescribing SMART based on available guideline recommendations. [Color figure can be viewed at wileyonlinelibrary.com]

Barriers to prescribing SMART included concerns about the black box warning (9.1%), insurance coverage (65.9%), paucity of pediatric literature (36.4%), resistance from patients/families (23.5%), and other (21.2%). Themes from free text responses to “any last thoughts/comments/concerns for us” included concerns about insurance/cost, familial confusion, how to integrate SMART with asthma action plan, how to manage SMART inpatient, safety concerns, lack of understanding from other providers, and device issues. Some providers reported that only turbohalers are approved in their practice area or that the government only allows the medications above a certain age.

4. Discussion

Our survey revealed multiple concerns from pediatric pulmonologists with some common emerging themes. One concern expressed by respondents was the lack of pediatric data. This represents a significant issue that remains unaddressed; however, pharmaceutical companies are unlikely to do additional research in younger children due to challenges with study recruitment, pharmacology and dosing, safety, and limited profitability. It's concerning that apprehension remains about the previous black box warning on LABAs when subsequent large studies including children demonstrated safety [6].

Insurance coverage of SMART and affordability continue to be problematic, including insurance only covering one inhaler per month [5]. Templated responses about evidence‐based guidelines can help with insurance coverage. One way to decrease administrative burden for offices is saving prescription favorites with comments to pharmacy allowing brand name Symbicort/Breyna or generic budesonide‐formoterol with maximum doses. Coupons can mitigate cost burden for those with private insurance.

Clinicians from the US were significantly more comfortable than international clinicians with SMART. US clinicians use both NHLBI and GINA guidelines significantly more than international clinicians, who use GINA guidelines more exclusively; this makes sense since the NHLBI guidelines were created by a US task force. This may further explain US clinicians being more comfortable prescribing SMART since the NHLBI guideline has a younger age cut off of 4 years. Other reasons that non‐US clinicians are less comfortable prescribing SMART is that there are device limitations (only turbohalers available) or cost limitations (only available for ages 12 and up). Our survey also showed pulmonologists earlier in their careers are more comfortable with prescribing SMART than pulmonologists later in their careers; reflecting that changes in standard of care can be more challenging to adopt for physicians in practice for longer. This observation is likely influenced by multiple factors such as lack of knowledge or more experience with previous practice standards which are worth investigating further to help target teaching.

Confusion and lack of SMART education were major concerns in our survey. Pediatric pulmonologists shared that families, patients, pharmacists, emergency room physicians, and school nurses have a lack of understanding of SMART or clarity about asthma action plans with SMART for acute management. We need updated asthma action plans to align with SMART, including what to do in the yellow and red zones as well as inpatient. Nonetheless, clinicians believe that SMART is more intuitive for patients and offers an opportunity for patient‐centered care [5]. These sentiments represent areas for clinicians to help focus education to mitigate confusion.

SMART has transformed asthma management, and continued efforts with stakeholder education are crucial. While this study provides insight into pediatric pulmonologist experience, it doesn't incorporate the perspectives of other involved parties in asthma management such as patients, families, nurses, pharmacists, or other physicians outside of pulmonology. These other perspectives remain essential to effective implementation of SMART, and further study is needed to assess these perspectives and address gaps in understanding. This survey demonstrated continued barriers to SMART implementation and potential areas to target continued education and advocacy locally, nationally, and internationally.

Author Contributions

Charles Slocum: writing – original draft, visualization, writing – review and editing, formal analysis, data curation, resources, project administration. Mackenzie Wyatt: formal analysis, data curation, review and editing. Annique Nyman: conceptualization, investigation, writing – review and editing. Anne Coates: project administration, conceptualization, investigation, funding acquisition, writing – review and editing, methodology, validation, supervision. Deborah R Liptzin: conceptualization, investigation, funding acquisition, writing – review and editing, methodology, validation, project administration, supervision, software.

Funding

The authors received no specific funding for this work.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting Figure S1: Comprehensive list of the survey questions provided to study participants with available response options.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.