Scaling up the Integrated Care Pathway for Acute Asthma to All Osakidetza Pediatric Services Through a Cluster-randomized Sequential, Multiple Assignment, Randomized Trial (SMART) Design

Although evidence-based, multidisciplinary approaches have demonstrated efficacy in the management of pediatric asthma, substantial variability persists in the quality and outcomes of care for children experiencing acute asthma exacerbations. The Integrated Care Pathway for Acute Asthma - ASMAbat is a structured, evidence-informed framework designed to standardize care for patients presenting mild to moderate asthma attacks. It delineates the essential steps in clinical assessment, pharmacological management, and interprofessional coordination of care. Additionally, it incorporates quality indicators relative to diagnostic accuracy, assessment of disease severity, appropriateness of medication prescription, and the experiences of families and healthcare professionals. These indicators were refined through iterative consultations with key stakeholders (clinicians, families, and implementation partners) to ensure both clinical relevance and contextual feasibility.

The current study will be conducted across all Integrated Healthcare Organizations (IHOs) within the Osakidetza-Basque Health Service. This initiative builds on previous development and validation of the ASMAbat pathway in two IHOs, where implementation was evaluated using principles of implementation science. The expanded phase aims to systematically scale and adapt the pathway across diverse organizational settings within the Basque health system to enhance the quality, consistency, and sustainability of asthma care.

Three facilitation strategies have been developed to support implementation: (1) Internal Facilitation alone (Standard Scaling); (2) combined Internal and External Implementation Facilitation (IF); and (3) combined Internal and External Sustainability Facilitation (SF). Internal Facilitation is led by Clinical Leaders, professionals embedded within the health system who promote adoption and integration of evidence-based practices among their peers. External Facilitation is provided by experts with established experience in implementation science and quality improvement. External Implementation Facilitation focuses on supporting Clinical Leaders in diagnosing and addressing barriers to practice change using the Behavior Change Wheel framework, a theoretically grounded model for analyzing determinants of individual and collective behavioral change. In contrast, External Sustainability Facilitation emphasizes the identification and reinforcement of organizational, team-level, and individual factors necessary to achieve the long-term, system-wide institutionalization of the ASMAbat pathway into routine pediatric asthma management.

The overarching objective of this study is to evaluate the effect of scaling the implementation of the ASMAbat pathway across the Basque Health Service, with the overall goal of improving clinical management of acute asthma in children in accordance to recommended care and reducing variability across professionals and care settings. The primary scientific aim is to determine, among Pediatric Services demonstrating suboptimal response to the Standard Scaling (SS) strategy, the incremental effect of adding an Implementation Facilitation component on the appropriateness of the management of acute asthma episodes, which includes: a) the recording of the severity score, b) the assessment and recording of persistent asthma symptoms using the Pediatric Asthma Control Tool (M-PACT), c) the initiation or adjustment of maintenance treatment in cases of persistent asthma symptoms, and d) the administration of bronchodilator treatment via MDI with a spacer device. Secondary aims include evaluating, among services achieving adequate initial adoption through SS, the effect of introducing a Sustainability Facilitation strategy compared with maintaining SS alone during the subsequent phase, on the indicators of adequacy in the management of acute asthma episodes.

A Cluster-randomized Sequential Multiple Assignment Randomized Trial (SMART) design will be employed to test adaptive implementation strategies. All pediatric professionals belonging to 11 IHOs from Osakidetza-Basque Health Service and all acute asthma episodes in children aged 2-14 years during the study period will be included. During the first 8 months, all centers will receive the universal components of the ASMAbat Pathway and will be exposed to a standard scaling strategy (SS) composed of training for Clinical Leaders and pediatric professionals, electronic health record decision-support tools, audit and feedback, multichannel dissemination, and email reminders.