Weekly Literature Review: Healthcare Innovation and Access

Monday: Value-Based Physical Therapy for Chronic Pain

Summary

Lentz and colleagues present a conceptual framework for value-based physical therapy in managing chronic musculoskeletal pain. The model identifies how patient-therapist interactions, organizational policies, and health system structures collectively influence treatment quality and cost-effectiveness. By mapping evidence-based pathways, including early access, guideline adherence, and risk stratification,onto this multi-level framework, the authors demonstrate how physical therapists can align with healthcare reform priorities while improving outcomes and reducing the substantial economic burden of chronic pain.

Key Findings

• Annual U.S. pain costs reach $560–635 billion, with musculoskeletal conditions as major contributors

• Early physical therapy reduces utilization, costs, surgery risk, injections, and opioid use

• Direct access to PT (unrestricted in only 18 states) lowers expenditures with comparable or superior outcomes

• Guideline-adherent imaging reduces downstream costs and unnecessary services

• Risk stratification improves efficiency by aligning treatment intensity with patient prognosis

• Patient-therapist interaction level offers the most direct leverage point for value creation

• Organizational and system-level policies exert significant indirect influence on outcomes

Citation: Lentz, T. A., Harman, J. S., Marlow, N. M., & George, S. Z. (2017). Application of a value model for the prevention and management of chronic musculoskeletal pain by physical therapists. Physical Therapy, 97(3), 354–364. https://doi.org/10.1093/ptj/pzx019

Tuesday: Real-World Nonpharmacologic Back Pain Care

Summary

Roseen and colleagues evaluated nonpharmacologic low back pain treatment across 17 U.S. integrative medicine clinics, tracking 660 adults over 12 months. The study found that 70% received guideline-concordant care, primarily through acupuncture, chiropractic, and physical therapy combinations. While pain interference showed modest improvements (particularly among those with higher baseline severity), physical function changes were small and varied by baseline status. The findings suggest that integrative medicine settings can deliver recommended care at scale, though effectiveness depends on treatment dose, baseline severity, and implementation quality.

Key Findings

• 660 adults across 17 clinics; 66% had chronic low back pain; 75% female; mean age 51.6 years

• Service use: IM consults (56%), acupuncture (44%), chiropractic (24%), PT (19.5%), massage (17%)

• 70% received at least one ACP guideline-recommended nonpharmacologic treatment

• Pain interference improved modestly: −1.26 at 2 months, −1.98 at 12 months overall

• Largest gains in high baseline pain tertile: −4.35 at 12 months

• Physical function improvements concentrated in those with lower baseline function (+2.57 lowest tertile)

• Secondary benefits: reduced anxiety (−1.45), depression (−1.62), improved social participation (+2.23)

• Median visit doses often below RCT-identified effective levels (e.g., 6 vs. 12 chiropractic visits)

Citation: Roseen, E. J., Hurstak, E. E., Kim, R. S., Gao, Q., Greco, C. M., Vago, D. R., Saper, R. B., Kligler, B., McKee, M. D., & Dusek, J. A. (2025). Nonpharmacologic back pain treatment use and associated patient reported outcomes in US-based integrative medicine clinics. Global Advances in Integrative Medicine and Health, 14, 1–13. https://doi.org/10.1177/27536130251345481

Wednesday: Healthcare Complexity as a Barrier to Access

Summary

Levitt and Altman argue that systemic complexity, not just cost or coverage gaps, is a critical barrier to healthcare access in the United States. Drawing on a national survey of 3,605 insured adults, they document widespread confusion about coverage, administrative hurdles in finding care, and procedural disenrollments that lead to delayed treatment and financial strain. The authors emphasize that simplification through better enforcement of existing consumer protections offers a pragmatic pathway to improving health system usability, particularly for vulnerable populations navigating mental health services, chronic conditions, or frequent care needs.

Key Findings

• 60% of insured adults reported insurance-related difficulties in the past year

• Problem rates highest among those in poor health (67%), needing mental health services (75%), and frequent users (80%)

• 15% reported worsened health due to insurance problems; over 25% incurred higher costs

• About 50% did not fully understand their coverage; 33% unclear on what costs were covered or owed

• Medicaid post-COVID redeterminations led to millions of disenrollments, 75% for procedural reasons

• Medicare beneficiaries face average of 43 plan choices; ACA marketplace enrollees face 100+ options

• 60% unaware of appeal rights; 76% didn't know which government agency could help

• Only 50% of those experiencing problems eventually obtained needed care

Citation: Levitt, L., & Altman, D. (2023). Complexity in the US health care system is the enemy of access and affordability. JAMA Health Forum, 4(10), e234430. https://doi.org/10.1001/jamahealthforum.2023.4430

Thursday: Health Systems Must Precede AI Implementation

Summary

McCoy and colleagues challenge techno-optimistic narratives about artificial intelligence in global health, arguing that AI cannot advance health equity without foundational health system investments. Using Paul Farmer's "5S" framework—Staff, Stuff, Space, Systems, and Support—they demonstrate how workforce shortages, resource scarcity, infrastructure gaps, weak governance, and inadequate social support undermine AI's potential in resource-constrained settings. The authors contend that prioritizing health system strengthening is both an ethical and practical prerequisite for responsible AI deployment, cautioning against technological solutions that ignore or worsen existing inequities.

Key Findings

• Staff: Global workforce shortages limit capacity; AI risks displacing clinical judgment without proper support

• Stuff: Basic medicines and supplies must precede AI; opportunity costs may divert resources from essential care

• Spaces: Physical infrastructure deficits (electricity, water, facilities) cannot be leapfrogged digitally

• Systems: Weak governance and fragmented records undermine AI integration; local leadership is essential

• Support: Community structures must be strengthened to ensure equitable AI-enhanced care delivery

• Case example: Google's diabetic retinopathy model failed in Thailand due to contextual mismatches

• Power dynamics: AI development concentrates control in wealthy institutions while creating dependency in LMICs

• Historical parallel: Global institutions promoting AI previously supported policies that weakened health systems

• Ethical imperative: Health system strengthening must precede AI to avoid exacerbating inequities

Citation: McCoy, L. G., Bihorac, A., Celi, L. A., Elmore, M., Kewalramani, D., Kwaga, T., Martinez-Martin, N., Proa, R., Schamroth, J., Shaffer, J. D., Youssef, A., & Fiske, A. (2025). Building health systems capable of leveraging AI: Applying Paul Farmer's 5S framework for equitable global health. BMC Global and Public Health, 3(39). https://doi.org/10.1186/s44263-025-00158-6

Friday: Senior Adults and IoT Healthcare Device Adoption

Summary

Malarvizhi and colleagues examined factors influencing Indonesian seniors' adoption of IoT-enabled healthcare devices, extending the established UTAUT technology acceptance model with perceived product value and perceived technology accuracy. Surveying 772 participants, the study found that perceived product value strongly predicted both attitudes and intentions to use these devices, while perceived accuracy influenced attitudes but not intentions directly. The findings reveal that seniors prioritize perceived benefits and reliability over ease of use, with age and gender moderating adoption pathways—suggesting that successful IoT healthcare implementation in emerging economies requires tailored strategies emphasizing device value and trustworthiness.

Key Findings

• 772 Indonesian senior adults surveyed using partial least squares-structural equation modeling

• Perceived product value (PV) emerged as strongest predictor of both attitude and intention

• Perceived technology accuracy (TA) significantly influenced attitude but not intention directly

• Performance expectancy did not predict attitude (contrary to standard UTAUT predictions)

• Effort expectancy and facilitating conditions did not predict intention in this population

• Social influence significantly affected both attitude and intention to adopt

• Age and gender moderated multiple relationships: men relied more on performance expectancy; women on effort expectancy, social influence, and facilitating conditions

• Attitude mediated most relationships between UTAUT constructs and behavioral intention

• Seniors prioritize perceived value and accuracy over ease of use in healthcare technology decisions

Citation: Malarvizhi, C. A. N., Al Mamun, A., Reza, M. N. H., & Yang, M. (2025). Seniors' attitudes and intention toward IoT-enabled healthcare devices in emerging economies. Scientific Reports, 15, 13320. https://doi.org/10.1038/s41598-025-97507-0

Weekly Overview: Bridging Access, Innovation, and Implementation

This week's literature reveals a healthcare landscape grappling with the tension between promising innovations and persistent structural barriers to equitable, accessible care. Three central themes emerge across these diverse studies:

1. Implementation Fidelity Determines Real-World Effectiveness

Both the value-based physical therapy framework and the integrative medicine study underscore that evidence-based interventions only deliver their full potential when properly implemented. The modest outcomes in the Roseen study, despite 70% guideline concordance, reflect insufficient treatment doses and variable implementation quality. Similarly, Lentz's framework identifies early access and risk stratification as leverage points that remain underutilized due to organizational and policy barriers. The lesson: having the right interventions matters less than delivering them correctly and consistently.

2. Systemic Complexity Undermines Healthcare Value

Levitt and Altman's examination of insurance complexity and McCoy's critique of premature AI deployment both highlight how systemic dysfunction creates barriers that individual interventions cannot overcome. Whether it's insured patients unable to navigate coverage to access recommended care, or AI tools deployed in settings lacking basic infrastructure, complexity and fragmentation systematically erode healthcare value. The 60% of insured adults experiencing insurance-related problems suggests that access barriers extend far beyond the uninsured, affecting care utilization even when coverage exists.

3. Context and User-Centricity Are Non-Negotiable

The Indonesian IoT study and the AI critique converge on a critical insight: technology adoption and effectiveness depend on alignment with user needs, capacities, and contexts. Seniors' prioritization of perceived value over ease of use challenges assumptions about older adults and technology, while the failure of Google's retinopathy model in Thailand demonstrates the risks of context-blind deployment. Both studies argue for co-design, local leadership, and attention to social, cultural, and infrastructural realities, whether implementing IoT devices in emerging economies or deploying AI in under-resourced health systems.

Key Implications for Healthcare Leaders

For Clinicians and Delivery Organizations:

• Implement evidence-based pathways with attention to treatment dose and fidelity

• Use risk stratification to target resources where they'll have greatest impact

• Simplify patient navigation and administrative processes

• Engage patients in shared decision-making, recognizing diverse priorities across demographics

For Health Systems and Policymakers:

• Address systemic complexity through enforcement of existing consumer protections

• Invest in health system fundamentals (workforce, infrastructure, governance) before scaling technological solutions

• Expand direct access to effective nonpharmacologic treatments

• Design reimbursement and regulatory structures that support guideline-concordant care

For Technology Developers:

• Prioritize perceived value and accuracy in healthcare device design

• Engage end-users and frontline workers in co-design processes

• Ensure technological solutions address rather than worsen existing inequities

• Account for infrastructural, governance, and workforce prerequisites for successful implementation

These studies collectively argue that healthcare improvement requires not just better interventions or technologies, but fundamental attention to implementation quality, systemic simplification, and contextual fit. The path forward lies not in choosing between innovation and infrastructure, but in ensuring each enables the other.