A Deep Dive Conversation with Dr. Andrew Sauer about COVID, Heart Failure, and the Patient Experience

As we settle into the “new normal” in healthcare, it is important to address what has changed and will change as the situation twists, turns, and evolves. At the center of it all is, of course, the patient and their experience. Over the last several months, I have connected with various leaders in healthcare to discuss their thoughts on where they are now and where they are going as they navigate their care delivery. I hope that in sharing their perspectives, we can all learn lessons in leadership, compassion, technology and how the patient experience may be affected.

I recently had an educational and in-depth conversation with Dr. Andrew J. Sauer from KU Medical Center and University of Kansas Health System. Dr. Sauer is a practicing cardiologist, Associate Professor, opinion leader, accomplished program builder, frequently cited author, and father — devoted to patients suffering from heart failure. Graduating MD with Distinction in Research, University of Rochester, he completed training in academic internal medicine (MGH, Broad Institute of MIT, Harvard Medical School) and cardiovascular medicine (Northwestern University). At age 33, Dr. Sauer was recruited by the University of Kansas to co-found and grow an innovative contemporary heart failure, VAD and heart transplant program. While serving as inaugural Director from 2015-2020, the comprehensive heart failure and transplant patient survival rates rose to among the highest in the nation. He also helped his team innovate a high volume and pioneering telehealth remote monitoring program. 

As an expert in heart failure therapies, Dr. Sauer has authored numerous articles accumulating thousands of citations. He has also served as a national and global steering committee member for innovations and investigations partnering with Medtronic, Boston Scientific, Abbott, Amgen, among several others. He is frequently sought for consultative input regarding device therapies, emerging technology, and telemedicine innovations as a particular focus. He is an impressive, humble leader with a lot to say! 

1. Sauer, please tell me about yourself and your journey to this very successful program you have built at the University of Kansas Health System.

Dr. Sauer: I grew up in Nebraska and went to college there. Then I went to upstate New York for medical school at the University of Rochester. At that point, I was hooked up with a giant in the EP field by the name of Arthur Moss. He was my first mentor. He basically pioneered cardiac resynchronization therapy and implantable cardiac defibrillator therapy as the lead investigator for all of the original trials that brought that technology to the guidelines. He had spent his training back in the '50s at Mass General and then had ultimately worked with the space monkeys and had a really interesting career. Dr. Moss said, "I'm going to help you along and then I'm going to send you to Boston." 

I did my residency at Mass General and decided I wanted to do cardiology pretty early and went back to Chicago to be a little closer to the Midwest. I got really interested in the mechanical circulatory support and LVAD space, which wasn't really taking off as quickly in Boston. They were still focused very much on transplants. Meanwhile, Chicago was all in and so everybody in Chicago was VAD, VAD, VAD and the trials were happening. I thought, "If I'm going to do this, I need to go to a place where a lot of that's happening." I went to Northwestern; I did my fellowship and advanced fellowship in heart failure and heart transplant there. 

Then this crazy proposition came about where the University of Kansas Health System reached out to one of my surgical colleagues (who's still my partner today) and said, "We want to have you guys come down to Kansas and build a brand new heart transplant program." The long story short, they convinced us. My surgical partner and I left Northwestern very early in our careers, much to the resistance of our mentors.

I think I understand how people can have preconceived notions about this region. From a career standpoint, what we realized was this was a bold and courageous move, if we can pull this off, we have an epidemic in our backyard where no one else is in the space. If you fast forward to where we are today, we went from no transplant program, no VAD program, no heart failure program, no remote monitoring program to where we are today. As of this week, there have been 24 transplants, 31 LVADs so far this year. We're pushing 150 for the program and we just did our 86th (I think) transplant as a program

I'm most proud of the fact that the city of Kansas City now delivers around 70 heart transplants a year with some of the best outcomes in the country.

We're slated to have about 13 to 15,000 heart failure encounters across 10 locations scattered across the state and the city. We have the largest remote monitoring program for heart failure in the region. We've become branded as the regional leader in remote monitoring. We have 200 patients with CardioMEMS? and another 50 with HeartLogic?, and we're the ultimate laboratory for this in the country.

What I always say is, it's all about your “why,” it's all about your mission. And our “why” has always been very focused on we're here to provide the best heart failure therapies available anywhere in the world for the state of Kansas and the Kansas City metro. 

It didn't exist five years ago, that wasn't what patients were getting. This might be the best city to be transplanted in because of these programs. What we did is ultimately push the envelope and be competitive. They were only doing about 40 to 50 transplants when we got here, which is a big number, but now the city is doing close to 80. This could be a banner year for our city, and for a city of two to three million people to do 70 to 80 transplants, that's big.

2. Profound changes in healthcare are happening quickly and have altered the face of patient education permanently. Patients are reluctant to return to the hospital. This creates a significant challenge for the entire healthcare sector and they will need to rethink care delivery across the board. From a broad perspective, what changes do you feel need to be made to address today's patient needs, fears, their hesitancy to come to the hospital for necessary surgeries and procedures? And how does this relate to your heart failure patients dealing with their chronic condition?

Dr. Sauer: First of all, COVID has been devastating to more than just the patients who get COVID. Sadly, the literature has borne out what we all feared would happen, which is that because of the fears of COVID, and I'm not going to dismiss the fear of COVID, and the anxiety especially early on when we had so little information, was that people didn't seek medical care. But in the wake of that, there was an amazing and an unprecedented shutdown where people literally hid in their houses for six weeks. There were six weeks across the globe where no one knew what to do. It wouldn't have mattered if we had telemedicine or didn't have telemedicine, these patients are not going to leave their home.

We were all concerned about how that would impact cardiovascular patients, patients with cardiovascular disease or risk factors, and of course, when the COVID data comes out of China you see the number one risk factor for complications of COVID is if you have cardiovascular disease. My patients, our patients in the heart failure community, were the most vulnerable at the time that this came out and the most terrified. So, they just shut down. We had patients just canceling left and right before we had a chance to fully figure out how we're going to catch up… even though we had the technology, the remote monitoring and the telemedicine in place from the beginning.

Heart failure admissions dropped, heart failure access to care dropped, cardiovascular care, coronary care dropped, and ultimately people died. The death count for COVID is not just how many people have died of COVID, it's also how many people died because they did not seek care. 

We know that the number of deaths this year, in terms of mortality across the country, is significantly higher for this season. But a lot of people are focusing on the COVID deaths. I think we do need to talk more about how we drill down and see how many people ultimately died of this lack of access of care.

3. What are your thoughts on COVID in those early months? 

Dr. Sauer: History is going to be interesting, because we're going to look back and say, maybe we could have had more COVID deaths, but maybe we could have had less non COVID deaths if we had been able to really adjust to this, about how we were messaging. We terrified patients. I was very concerned about that. One of the hashtags I liked to use was #keepthepatienthome, because I've been out there, working out there in the community, saying the best thing for patients and their referring cardiologists or heart teams, and their community is to keep the patient in their home. The home is not just their physical home, it's their community. It's their local caregivers, their family, their friends, their primary care physician. 

We've figured out how to tailor our care to each region, but the theme has always been, how do we partner with local caregivers, shared care, and how do we use technology? Even before COVID, we had a very sizable remote monitoring program, and we had an active telemedicine program. We were embracing this before the government said, "Yeah, here's the open door." 

4. So, are there any silver linings that will come from the COVID experience? 

Dr. Sauer: In any devastating crisis, what rises out of the ashes can be really beautiful. Especially if we can get beyond some of the divisive language going on right now in the politics, but I think most of us in the healthcare field are trying to find ways to turn this into an opportunity to really change the field. I don't think we're ever going back. Telemedicine was something we were doing before COVID, but it wasn't fashionable, and people scoffed at it and laughed at it and thought, "Yeah, that's a thing, but it's not a thing." We had a hard time getting patients to buy in. A lot of patients would no show because they just didn't really see this is a legitimate thing. Now, everybody wants to have their doctor visit over Zoom if they can. 

The world has completely changed its approach to whether telemedicine is a thing you can do.

5. Let’s talk about the dynamic of the patients in the hospital. What is the key to having the patient education make an impact, especially in regard to a chronic disease like heart failure?

Dr. Sauer: That’s the thing. The number one driver of morbidity and mortality and cost is the hospital environment. When patients come to a hospital they think “I'm going to get better” but they're dealing with a chronic disease. I try to tell this to my team and to my patients all the time the goal is to improve life expectancy and do the guideline based things that we know work and all of the great therapies and we have more therapies coming down the pipeline.

The other thing we need to do is really figure out creatively how to change this continuous circle of readmissions and readmissions. We're talking about a national readmission rate of 20 to 25% today when you're looking at the Medicare population, that's terrible. You get admitted once or twice more, your likelihood of dying within the next year is 50%. 

One of the other things I try to say a lot is, “we need to treat heart failure like cancer, because heart failure is more lethal than the vast majority of types of cancer diagnosed out there.” That's not what the public hears. They hear heart failure, they think diabetes, they think hypertension, they think chronic disease. What I've tried to work on in the community, including partnering with industry is how do we invoke a little bit more urgency as part of a public campaign to say, "You should be scared of your disease so that you go get the right care. Why would you get your heart failure care predominantly from your primary physician and a general cardiologist who only dabbles in heart failure?"

At least in terms of constructing the blueprint, we should have patients getting into heart failure teams and it's also a team- based sport just like cancer. You have teams of surgeons and oncologists, you have medical and surgical treatment, and you have nurses who are specially trained. Heart failure is no different. Education gets lost in all of this.

6. Heart surgery of any kind is a traumatic event. Patients often rely on support of loved ones during and after their hospital stay. With the new rules and limitations about visitors at hospitals, even at appointments, an important element has been lost. Family members and or friends serve as ears, eyes and advocates. Removing the support can sometimes lead to patient misunderstanding instructions, remembering less, ultimately influencing the course of recovery. When patients are more frightened, their capacity to receive information may also be diminished. How do you address this issue before and after procedures? 

Dr. Sauer: Every health system went through the stage where they basically had a “no visitor policy” unless absolutely necessary, and that was really scary. We had patients who were critically ill in the ICU and dying, and I could not get family members to the bedside to help make decisions and that was hard. Honestly, it was traumatizing. There's been some real trauma for healthcare workers who've had to see people die alone, suffer alone. I've had the nurses describe feeling like they have to basically play the role of the family member.

There's no doubt there are issues right now that we're still facing that get lost in translation. It's very hard to make decisions. We've had to really slow down and take the time to get loved ones not just on the phone, but oftentimes a FaceTime. Thank God for technology because almost everybody's got a smartphone where you can basically hit a button and you can get someone on a video. One of the challenges is just taking a lot more time for our teams. It's just harder to communicate when you hear, "Wait. What did you say? I can't hear, my phone's breaking up." 

When you're trying to educate someone on say a VAD or how to go home, how to manage the controller and how to manage the drive line, at least early on, there's just no way to do that well using technology, but that's what we've done. Again, I think the silver lining, though, is that patients have gotten better at this. They've seen Zoom as more of a normal thing. They're figuring out technology. We're all learning. 

I've had to learn how to become more comfortable doing meetings like this. This has become more normal. People are doing all kinds of things. This feels so weird to me, but I think it's normalizing technology and we are embracing it. I think that's what's good about all of this… we're never going to go back.

I think there's so many creative ways to do education and provide information for patients that don't rely upon the bedside moments where you only have so much time. We seem to just have less and less time every day. 

7. Does it diminish the experience for you when you can’t touch the patient? How do you bridge the gap with the lack of physicality in a hospital situation, with the covered faces and safety protocols? How do you adjust for the impact of that on patients?

Dr. Sauer: Absolutely, and I think we have to be sensitive to it. I've been in situations where I'm in an exam room, it's just the two of us and we're having a hard conversation. Part of my job is to tell patients they're dying, and there's no other way to say it. I've learned not to try to dance around it. You have to just come out and say, "You have a really bad disease, and you are dying of that disease, and we need to talk about what options we have to help you." Because I always say, we can always save lives or reduce disease burden, or relieve suffering. There's always something we can do for any type of patient with any prognosis, but you have to be able to talk about the disease and talk about what it means, and you have to then be able to get to the options. Sometimes, you have to say, "Hey, is it okay with you, if I can take off my mask to have a conversation? I'm going to step back in the corner of the room and if you want to take your mask off too..." They need to see that this isn't a robot talking to them. 

If they don't see your face, the face is a dynamic thing and you can't just look at someone's eyes and get the sense of their nonverbals and how they have the empathy and the compassion and that gets lost. There's damage that's done if you can't deliver that part of care. Part of caring for patients is the hand on the shoulder, it is the hand on the patient's hand, it is looking at them and listening and leaning in. And if you lean in, you got to put the mask on but if you can step back, there may be some risk, but everything we do in medicine is risk versus benefit.

Sometimes I think the risk of me leaving this mask on is that they're going to walk out of here thinking that I'm not compassionate, and they need compassion. That's part of the care. They need to feel heard. They need to feel validated. They need to have their anxieties and fears addressed, they need to have their questions answered, and they need to know that you're going to help them and that there's hope. Because one of the things I talk a lot about to my patients is, "So much of what you're going to hear is going to feel like I'm breaking you down, I’m breaking you down to hear the truth about your disease, then I'm going to give you the hope of what we can do."

How do you do that without a little bit of touch, and a little bit of contact. Sometimes you need to even have some tears shed both ways. Otherwise, there's no humanity left. I refuse to do everything one way in broad strokes and be religiously attached to any one way of doing things all the time. I recognize that I take risks and my family is exposed to those risks if I get sick, but the reality is, I feel like we have to maintain our humanity in all this and there's risks in everything we do. When I get on that little plane to go to Hays, technically I take some risk because that little plane could crash and that's it. We do that because we're trying to help save lives and help people in the middle of nowhere. That's why we get on the plane.

8. In your opinion, what is the single most important element that needs to be incorporated into today's patient experience and how could you see that effectively implemented?

Dr. Sauer: Well, telemedicine isn't the answer, but I think we need to refine the technology and the utilization of the technology to add some peripheral data points. I don't know how you do telemedicine for every heart failure patient if you don't have additional data points to replace what you would normally have at the bedside. Point of care ultrasound, we're looking at that, remote monitoring implantables, wearables, bedside technology, interfacing with local labs, we have to improve how we safely implement labs. Point of care labs at home, there's technology for that and also being able to access labs quicker and faster and have it be in real time.

I think that we need to reduce some of the dependence on it being a physician or nurse practitioner doing everything. We need to shift some of the burden of volume onto really highly trained and competent nurses. That's much better than having everything run through a nurse practitioner or a physician for every patient that can't get to the health system safely. There's not enough bandwidth. I think now that we're in, we need to really get all in and our health system is looking at investing in those things, but I think as a health system across the country, it'd be great to see us standardize what defines good telemedicine? For heart failure is going to look different than orthopedics. In heart failure, we should have content experts and thought leaders who are doing this and be part of government sponsored panels. 

Because nobody's regulating quality, everybody's doing telemedicine, but how good is it? We don't know that we're actually making a difference, and if all you're doing is saying, "Yeah, keep your meds the same." We know we're going to pay the price for that in a year as people regress in their disease.

9. Along the same lines, what’s the most important part of the patient experience going forward?

Dr. Sauer: It’s the power of education, it reduces fear. In fact, one of the pillars of leadership as a budding, growing student of leadership, one of the most important things that leaders do is drive out fear. It doesn't mean there's no reason for fear, but the leader stands up and says, "Okay, we have a known enemy and here's the blueprint of how we're going to take on the known enemy." That lowers the fear, and that creates a sense of calm, and people then start operating according to their rational brain. 

I want to help get the larger message out. There's got to be more than just coming up with new science. We have to figure out how to implement what we have in a more creative and a patient centered way. That's what it's about.

The Heart of the Matter 

 Dr. Sauer demonstrates that leadership matters. Teamwork matters. Innovation matters. Caring matters. Patients matter. Dr. Sauer and his team clearly represent a system of processes, people, and technology that achieve excellent outcomes, and the highest quality, safe, patient-centered care. With doctors like Dr. Sauer leading the charge, the patient experience will continue to improve. My deepest gratitude to Dr. Sauer for taking time out of his busy schedule to share his experiences and inspirational thoughts.

About the Author: Lisa Coleman is the president of RecoverRite. RecoverRite? was built from the patient perspective and is dedicated to improving the patient experience through custom online learning platforms and custom patient education tools for hospitals and practices.