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Functional impairments affect nearly one-quarter of US children. When children experience functional impairments, health and well-being are often substantially affected by nonpharmacologic supports, which can be as common as corrective lenses for poor vision or as critical as a tracheostomy and ventilator for respiratory failure. So-called durable medical equipment is defined by the US Centers for Medicare & Medicaid Services (CMS) as meeting 5 criteria: (1) durability, ie, withstanding repeated use; (2) used for a medical reason; (3) used in the home; (4) expected to last 3 years; and (5) typically only useful to someone who is sick or injured. Medical supplies are frequently essential as well, eg, suction catheters to maintain tracheostomy patency, tubing to deliver airflow from the mechanical ventilator to the patient, diapers for incontinence, parenteral feeding supplies, and syringes.

Despite the common use of durable medical equipment and supplies (DMES) in everyday care, DMES are poorly understood. General pediatricians commonly feel unprepared to manage DMES and delegate DMES responsibilities to other service teams and support staff.¹ Patients and families report substantial distress from DMES use and barriers to reliable access.^2-4 While researchers recognize that DMES use can both positively and negatively affect health and health services, the lack of standardization in measuring DMES use prevents addressing important knowledge gaps. For example, population estimates of overall DMES use are not well known, and research suggests that complications of assistive technology, one form of DMES, can contribute to overall hospital and ED use.^5,6 Addressing these challenges, Hotz et. al⁷ partner with clinicians, patients, and insurance experts to develop standardized DMES categorizations, and apply the categories to a large claims data set to describe DMES use in children.

Hotz et al⁷ distilled more than 2500 level II Healthcare Common Procedure Coding System (HCPCS) codes, the universal code set maintained by CMS and used by public and private payers to handle claims for products and services used in any care setting including the home or community, into 164 DMES types spanning 14 organ systems. By applying their classifications to a national sample of individuals aged 0 to 21 years from 12 US states available in the 2018 Merative Medicaid claims database, the authors quantified the prevalence, types, and annual per-member spending on DMES. Of 4 569 473 Medicaid-insured individuals in this age range, 782 425, or roughly 1 in 6, used DMES.

This DMES use totaled nearly 20% ($464 million) of all Medicaid spending for outpatient, community, and home health services. In aggregate, vision frames/lenses comprised the most considerable share of spending and applied to 27% of the sample. Across the population, 5 DMES types accounted for 60% of DMES spending, with parenteral supplies being the most expensive per individual ($14 745 per-member-per-year). As may be expected, DMES use was concentrated in more medically complex populations. For example, most children with 2 or more complex chronic conditions (61%) used DMES. Even among children with no identified chronic condition, 10% used DMES with an average spending $349 per-member-per-year, mostly for vision frames/lenses.

Other researchers have used HCPCS codes to characterize health and resource use in specific conditions more comprehensively. However, to our knowledge, there are no other examples of an exhaustive categorization of HCPCS codes into clinically relevant and recognizable classifications. Important future work should establish the reliability and validity of these classifications. Since the authors report that no DMES were excluded even if predominantly used by adults, these classifications might plausibly be applicable without considerable effort to entire populations including adults.

The authors astutely recognize that these data estimate the floor of actual DMES need and use. For example, if the authors had access to private insurance claims, their absolute numbers would be far higher, noting that Medicaid insures about half of children with special health care needs. Forgone DMES can occur from insurance claim denials, patient barriers to accessing services, clinician or health system order breakdowns, and more. Additionally, needed DMES are sometimes obtained through means not captured in claims, eg, lending agencies, out-of-pocket purchases, or do-it-yourself (or build-it-yourself) workarounds. At times, DME is obtained through home and community-based waiver programs, including for items that may not yet have HCPCS codes.^3,8 Many of these limitations illustrate the value and potential utility of the authors’ system.

Future applications of the DMES classifications proposed by Hotz et al⁷ could be used to identify patients who have a high probability of requiring DMES. The absence of DMES insurance claims in such populations could signal disparities in access to needed services which could be quantified, investigated, and addressed. Clinicians, payers, and/or policy makers might use similar approaches to guide improvement initiatives. The value of this direction is underscored by recent work illustrating how families create extensive workarounds to overcome DMES gaps, which pose unknown risks to their children.^3,4 Researchers might apply the authors’ classification system to determine expected patterns and profiles of concomitant DMES use. Understanding trajectories of longitudinal DMES use could guide families and clinicians in setting long-term expectations and plans as chronic conditions unfold or after major health events occur such as traumas or surgical procedures.

Another possible feature of this system is facilitating quality and safety initiatives involving DMES use. Fields et al⁹ illustrated how HCPCS codes can be incorporated into a quality improvement effort to reduce administrative inefficiencies in ordering DMES for patients.⁹ Since use of specific DMES types can be rare, and since safety and efficacy outcomes can be similarly rare, tools such as this are essential to facilitate larger population analyses with adequate statistical power. Reliably identifying specific DMES use within a population should enable clinicians and researchers to better identify both positive and negative health outcomes, in addition to the adverse events stemming from these products. Although prior studies have attempted examples of this,^5,6 these methods of identification have been susceptible to unknown reliability and validity or laborious methods limiting scalability. Finally, the authors’ classifications could facilitate long-term monitoring of temporal trends in DMES use and responsiveness to changes in supply and demand. While each of these future applications is clinically relevant to health care professionals and patients, particularly those with chronic and complex conditions, their success would remain difficult if not impossible in the absence of the important contribution of Hotz et al.⁷

Published: October 24, 2023. doi:10.1001/jamanetworkopen.2023.39581

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Adegboro CO et al. ÌÇÐÄvlog Open.

Corresponding Author: Ryan J. Coller, MD, MPH, Department of Pediatrics, University of Wisconsin, Madison, 600 Highland Ave, Madison, WI 53792 (rcolle@pediatrics.wisc.edu).

Conflict of Interest Disclosures: None reported.