SMART initiation low among PCPs, but several interventions could improve adoption
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Key takeaways:
- Only seven out of 22 children initiated on SMART were initiated by a PCP.
- However, PCPs supported interventions such as enhanced support for family education.
WASHINGTON — Single maintenance and reliever therapy was not commonly initiated by primary care providers, although PCPs supported efforts to improve adoption, a study showed.
“We were finding that in practice, a lot of patients who were eligible for [single maintenance and reliever therapy (SMART)], anecdotally, were not started on SMART,” Hannah Seay, MD, a resident physician at Children’s Hospital of Philadelphia, told Healio. “We were interested in trying to figure out what those barriers were so that we could hopefully implement strategies to improve adoption in the primary care network.”
In the study, presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting, Seay and colleagues examined initiation rates among SMART-eligible children aged 5 to 18 years (n = 49) who had two or more hospitalizations or ED visits for asthma.
used in the study, meanwhile, were taken from the electronic medical record.
The researchers also emailed surveys to PCPs (n = 58) across nine practices, who had conducted ED or hospital follow-up visits with the children, for input on potential SMART interventions for greater adoption.
They found that among the 46 children included in the study, “52% were never initiated on SMART,” Seay said. “We found barriers at primarily every single step of the process, [such as] identifying patients with poor control, patient comfort with transitioning from albuterol to SMART [and] getting the medications from the pharmacy.”
Of the children that were initiated, just seven were initiated by a PCP.
Seay and colleagues noted that the 30 PCPs who responded to the surveys supported multiple strategies to improve SMART adoption, which included:
- enhanced family education support (60%);
- EMR decision support to identify patient eligibility (53%);
- prior authorization support (53%);
- enhanced staff education (50%); and
- additional support for severe asthma medication management (43%).
Other suggestions made by PCPs for adoption improvement included:
- more consistency in SMART instructions and prescribing;
- tools that provide dosing and insurance coverage; and
- easier ways to identify patients on SMART.
“Now that we know what sort of facilitators we need, we can start to implement those in the primary care practice to increase those patients that can be started on SMART ... and then resend those surveys out and see if we’re getting higher adoption,” Seay said.
Reference:
- Seay H, et al. J Allergy Clin Immunol. 2024;doi:10.1016/j.jaci.2023.11.592.
Perspective
Back to TopRichard C. Calderone, DO, MPH, FAAP
Strengths of this study include not only identifying real-world challenges with implementation of SMART, but also addressing solutions that can aid in more appropriate prescribing.
Unsurprisingly, PCPs feel that insurance coverage limitations and prior authorizations are barriers to providing recommended prescribing. Tools to help identify and obtain insurance coverage are identified as solutions that could help with SMART adoption.
Family and staff education — along with EMR decision-making tools for eligibility — were the strategies that PCPs thought would help most with SMART adoption, highlighting the major role that EMRs have in guiding and supporting appropriate clinical disease management.
Perspective
Back to Top
There are many challenges in prescribing SMART from a PCP standpoint. Not that we are unaware of the importance of this approach to pediatric asthma care, but that the insurance and formulary systems create barriers to access and affordability of the medications available. The single most difficult barrier in my primary care practice is the prior authorization burden and inability to determine which medication is covered by the insurance. If I send in the first-line therapy, it may take days or weeks before the patient can pick the medication up from the pharmacy because the insurance will not cover brands or generics. At the end of the day, the typical PCP spends hours of their time and the time of their staff going back and forth with pharmacies and insurance companies doing the very best we can to get the clearly best medication therapy for our pediatric patients suffering from asthma.
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Seay H, et al. Abstract 564. Presented at: AAAAI Annual Meeting; Feb. 23-26, 2024; Washington, D.C.
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