Hari Nathan, MD, PhD, FACS, assistant professor, division of hepato-pancreato-billary surgery, University of Michigan, Ann Arbor, is the recipient of the 14th Joan L. and Julius H. Jacobson II Promising Investigator Award (JPIA) administered by the American College of Surgeons Surgical Research Committee (SRC). Dr. Nathan’s clinical focus includes the multidisciplinary treatment of tumors of the liver, bile duct, pancreas, and stomach. He has particular interests in the treatment of liver metastases from colorectal cancer and primary liver cancer (hepatocellular carcinoma and cholangiocarcinoma). Dr. Nathan uses minimally invasive techniques, including laparoscopic and robotic approaches, for both benign and malignant diseases when appropriate.
Dr. Nathan’s overarching research goals are to better understand variation in the quality and cost of care for surgical patients, and to identify strategies for improving the quality and cost of care. He has studied surgical care in the Medicare program and has made important contributions to our understanding of how preoperative patient risk and hospital factors affect the occurrence of complications and cost of care. In particular, his work had been instrumental in demonstrating that perioperative complications are a chief driver of surgical expenditures and that patients with multiple medical comorbidities incur outsized costs when they experience complications, even at high-volume hospitals. This concept has clinical face validity, but had not been empirically proven until Dr. Nathan’s work.
As multi-hospital entities come to dominate the health care industry, Dr. Nathan’s ongoing work will provide a template to study the quality and cost of surgical care in other patient populations as well. In addition to a K08 award focused on accountable care organizations (ACOs), Dr. Nathan is a coinvestigator on an R01 from the National Institute on Aging focused on understanding the impact of other Medicare payment policies on surgical care for the elderly.
As a junior surgical resident with ambitions to become a surgical oncologist, Dr. Nathan initially planned to spend a year obtaining formal clinical research training, followed by two years in a tumor immunology laboratory. Taking courses in biostatistics and epidemiology during that first year at the Johns Hopkins School of Public Health, Baltimore, MD, rekindled an interest in quantitative science that led him to an undergraduate major in biomedical engineering. He decided not to pursue training in translational science, but instead to focus his efforts on clinical research in surgery.
Over the last 10 years, Dr. Nathan’s research interests have evolved from a focus on clinical topics such as cancer staging and prognosis to an interest in factors driving physician treatment variation for liver malignancies. He had exposure to advanced econometric methods and collaborators that allowed him to bring novel statistical techniques to bear on these clinical questions. These projects led to national podium presentations and publications, and ultimately a PhD. Most importantly, he learned that he drew the most satisfaction by applying innovative approaches to practical questions in surgical care.
As Dr. Nathan completed training, he began to consider what research contribution he wanted to make as a surgeon-scientist. He witnessed the variation in resource use involved in complex cancer care and sought to use his training to understand this problem. Early in his first year on faculty, he published work that elucidated the reasons for this cost variation. Given his interest in health care policy and a desire to do work with a high public health impact, he decided to expand his research focus with the goal of working to improve the efficiency and quality of surgical care delivery.
As a junior faculty member, Dr. Nathan focused on understanding variation in Medicare surgical expenditures. He has found significant variation within small geographic areas, highlighting the potential for local referral of patients to improve quality and costs. He also has identified a small subset of patients who incur a disproportionate share of costs. In fact, treatment of high-risk patients at low-quality hospitals has a synergistic effect on costs, suggesting that even a very selective referral strategy would have significant effects on outcomes and costs. He has found that the cost of managing complications varies widely between hospitals, suggesting that efficient management of complications may be another strategy for savings.
Dr. Nathan continues to apply these insights to identify potential solutions to low-value surgical care. He has completed the first evaluation of surgical costs in the Medicare ACO program. Now that mature data are available, he will further explore the potential for prospectively identifying high-cost surgical patients within ACOs for targeted intervention, such as prehabilitation or selective referral to other hospitals. He has received a grant from Blue Cross Blue Shield to perform a similar analysis using data on privately insured patients, highlighting the fact that many stakeholders are keenly interested in this work. In the next phase, he will define how population health managers in multi-hospital networks can use his team’s findings to optimize outcomes and costs.
His long-term goal is to be a translational health services researcher in surgical population health who can bring insights from his research to inform policy decisions to improve the efficiency of surgical care. With his K08 award, Dr. Nathan is supplementing his skills with training in econometrics and health policy evaluation to accomplish this goal. He believes it is critical that surgeons be involved in the evolution of health care policy and financing to ensure a seat at the advocacy table. The JPIA will help him define a novel, practical, population-based approach to surgical care.