Interview with Robert Sweetow & Kevin Lindemann
Topic: LACE® now Integrated in Sycle.net
CAROLYN SMAKA: Hi Robert! While many professionals may be familiar with LACE® (Listening and Communication Enhancement), can we start with an overview?
ROBERT SWEETOW: Sure - I think the most important thing to know about LACE® is that it is a program designed to develop attention and to improve a patient's focus. We know that more listening effort is required for a person with hearing impairment than for a person who has normal hearing. LACE® was designed to address listening effort. by improving focus, teaching good communication strategies such as what to do when communication breaks down, and by building confidence. All of these things are well known to audiologists, but these are not to a person who is experiencing hearing loss and is rapidly losing confidence in their communication abilities.
An important component of LACE®, in addition to providing communication strategies, is listening training in the situations that are most difficult. These situations include when there are multiple talkers, when there is a single background talker, when speech is very rapid, and when there is background noise. It is great when people can manipulate their environments or get others to speak slowly, but the reality is that there will be situations that require enhanced focus.
LACE® provides feedback after every task to the patient, so that they recognize, "Oh, what I thought I heard is actually what was said," or, "What I thought I heard was not what was said". The patient then has the ability to repeat the task.
SMAKA: LACE® gets progressively harder as the patient improves?
SWEETOW: Yes, that's exactly right. It is self-paced, and that's essential for effective, individualized training. If patients want to work on LACE® slowly they can, or if they want to progress very rapidly they can. It's an adaptive procedure, and that's a key component. When trainees succeed at a certain level, they then move to the next level. More specifically, in speech-in-noise testing for example, if they're able to repeat a sentence in noise, then the next sentence is going to have a signal-to-noise ratio (SNR) that is 2 dB worse, so the task is more difficult.
If they miss the task at the more difficult SNR, it will go back to the easier SNR. If they get it, it will again become 2 dB worse, and so on. The adaptive changes are made strictly based on the performance of the patient.
SMAKA: How long is each session?
SWEETOW: The sessions take most people approximately 20 to 30 minutes.
SMAKA: What age is LACE® appropriate for? I'm assuming my 12-year-old son could use LACE®, but what's the lower age limit?
SWEETOW: LACE® was designed for a 5th grade reading level - so approximately 10 to 11-years of age would be the lower limit.
I think that there have been some children as young as age 8 that have used it, but it is not specifically recommended for children under age 10, and we have not tested it out on the pediatric population.
SMAKA: Robert, I know that initially LACE® training was recommended for 20 days, and now with LACE® online or LACE® integrated with Sycle.net the training time is 11 days. How was it possible to reduce training time from 20 days to 11 days?
SWEETOW: It's interesting. The original reason why a 20-day training period was recommended was because the time period coincided with the typical hearing aid trial period. We figured five days per week training (weekends off) for four weeks.
The reasons why training has now gone down to 11 days came out of the data that have been collected with LACE®. One of the great things about LACE® is that there is a tremendous body of data behind it. There is a large central data base that has information from LACE® users. The data are of course heavily encrypted and people's identities and confidentiality are protected, and these data are used to refine the program and inform our recommendations.
In our profession, when we publish studies and when we present research, we usually talk about using a small number of subjects, such as 6 or 10 or 12. If you look at studies published in the American Medical Association (AMA) journals, it is typical to see numbers of 2,000 or more subjects. With LACE®, we have data from thousands of subjects. These data enable us to see trends over time that we would not be able to see from studies using a handful of subjects.
From these data that have been collected over the years we see certain trends. For example, most of the gains that are made from LACE® training are made within the first ten days. In fact, a significant amount of the gains that are made from the training are made within the first three or four days. We know that there's a very high correlation between LACE® training and hearing aid returns for credit. In other words, people who do LACE® training are less likely to return their hearing aids for credit. Now, part of that may be because people who do the training are more motivated to succeed and it may not necessarily be a direct result of the training per se. However, we have found that even people who complete only a couple of days of LACE® training are much less likely to return their hearing aids than others. That is part of the reason we were able to change the training time from 20 days to 11. In addition, the biggest limitation with LACE® or any other form of auditory training is that it's difficult to get people to comply with the recommendation to do it.
SMAKA: Right. It's just like getting patients to do their PT exercises at home, or to follow a specific diet regimen.
SWEETOW: Exactly. So, we felt that 20 days of training might be imposing too much on patients, in terms of their time, and that the time commitment could be barrier to them complying with the recommendation to use LACE®. And since the data show that most of the gains that are made with LACE® are made within the first 10 days, we changed the recommendation.
SMAKA: You mentioned that people who use LACE® are less likely to return their hearing aids for credit. What other gains are you referring to?
SWEETOW: The gain we are referring to is the actual ability to process speech in difficult environments. Whenever I am explaining LACE® to someone I stress the fact that LACE® has nothing to do with hearing. LACE® has to do with listening. Hearing aids help hearing, but hearing is not the same as listening. The gains are made, I believe, because of the additional focus that LACE® teaches the person to listen.
Listening requires attention and intention, and just because someone has good hearing does not mean that they're a good listener and vice versa. Some people that have very poor hearing are very good listeners because they really focus. LACE® teaches a person how to focus, how to focus when there's background noise, how to focus when speech is coming at a rapid rate, when there's another speaker in the background, and when there's other distractions in the background.
LACE® measures progress in two ways. The first is by looking at the SNRs that a person can correctly listen at on a day-to-day basis as they do the training. In addition to daily tracking of the scores on the competing message test, the word memory test, the speech in babble test, and the rapid speech test, there is an adapted QuickSIN test as part of LACE® that has been licensed through Etymotic. We can therefore also measure progress as gains in QuickSIN score.
As the person completes their work, the patient can access progress, the patient's audiologist can assess progress, and without knowing who the patients are, our researchers can also access the data. We can see what the trends are, how most people are doing, and how long it takes them to achieve progress.
SMAKA: Do we know what the long-term gains are? So what about someone who used LACE® for ten days, and you test them nine months from now?
SWEETOW: That's a good question, and the answer is we really don't know. When we did our original study on LACE® we measured out six months, and we found two groups. The larger group did retain their gains over a six-month period. There was a smaller group that dropped back not all the way down to their baseline, but towards their baseline. So we recommended that some people may need booster courses in LACE®, such as a refresher course every six months.
How long will a person retain the training? We don't have firm data one way or the other on that. Remember that LACE® is not changing hearing or having a sensory effect;rather, the goal is to teach strategies and to create gains in confidence, which are very important.
SMAKA: I used to run adult aural rehab groups and believe that confidence has a very significant impact on outcome and communication effectiveness.
SWEETOW: I agree. I think that the whole domain of confidence is something that a lot of professionals overlook. When patient are not confident about their communication skills they will drop out. It's one of the reasons Jennifer Henderson Sabes and I developed the Communication Confidence Profile (Sweetow & Sabes, 2010) that looks at whether a person is confident and what they will do when a communication breakdown occurs. LACE®, by providing constant feedback to the person while they're doing the training, helps build confidence. Along with confidence LACE® teaches communication strategies and trains the patient to focus, and there is no reason why those skills shouldn't be retained over time. The flip side is that overtime hearing may get worse, of course, so sensory abilities may degrade.
SMAKA: Right, and there are a lot of other factors involved, too. For example, over time the person had a lot more practice with their hearing aids, they may have had more fine-tuning adjustments, too.
SWEETOW: Absolutely. There are many variables that come into play, including the issue of cognitive declines as people get older.
SMAKA: Kevin from Sycle.net is here to talk about how LACE® and Sycle.net are now integrated. What do you see are the benefits to that integration?
SWEETOW: We earlier mentioned compliance and I think one of the barriers in the past for some people to do LACE® training has been the use of computer discs. Let's say a patient brings the LACE® discs home and has an issue such as the computer screen freezing or a problem with the disc. Immediately that will turn patients off and they probably won't continue with the training. The Sycle.net integration has made it more seamless.
Everything we can do to make the whole process simpler for the patient is important. If patients feel imposed upon and if they don't feel that the professional really believes in the purpose of LACE® training, they're not going to do it. I think a demonstration is very useful. I just went on the Sycle.net site to see how easy it is to use, and it is really easy. They've made it much easier than the early days of LACE®, certainly.
SMAKA: Kevin, what were the reasons why you decided to integrate LACE® into Sycle?
KEVIN LINDEMANN: We saw the opportunity to provide a totally new platform for LACE®, as Robert said, that facilitates ease of use from the patient's side. In addition, there are definite benefits for the clinician as well. LACE® online is something new and fantastic and it's easy for the patients to complete and it's simple for the providers and clinicians to manage and monitor compliance with.
SMAKA: I'm an audiologist using Sycle. How does the process work if I have a new patient I would like to use LACE®?
LINDEMANN: You essentially select a patient and associate a LACE® online access code to the patient. Sycle produces a patient handout with the LACE® access code and web address and you simply print it and hand it to the patient. As Robert mentioned, LACE® online is easy and intuitive, that's all they really need. The patient sits in front of their computer and they enter their access code and they create their profile, and they get started with day one of training.
Now, with a do-able 11-day training that's just as effective, patients will find it's an intuitive, sleek and engaging experience to complete the training.
SMAKA: You mentioned that the integration of LACE® into Sycle also was beneficial for professionals. How so?
LINDEMANN: In addition to being able to easily assign a patient an access code,
the integration addresses what Robert mentioned has been a barrier in the past - compliance. Now, with Sycle as the hub, LACE® online is one of the spokes. So, after the patient goes home, starts using LACE®, and completes day one of training, real-time data is sent back to the Sycle patient summary. The professional can view it at any time.
Let's say that the professional has time in his or her schedule for paperwork or reports. In just a few minutes, they can see all of the information for patients using LACE® online in Sycle. They can either go in to individual patients' records in Sycle, or to a global LACE® online report in Sycle. Either way, they can see the status for each patient using LACE®, who has dropped off, who hasn't logged in, etc. We've also implemented a cutting-edge notification system within the patient summary and also the appointment summary, that provides information such as "This patient hasn't logged in to LACE® in six days".
This information enables me to instantly act on it if I choose. I go into my report, I see that my patient hasn't logged in in six days, I click on the patient's name and I'm brought right into the Sycle interface, into the LACE® online section of the patient summary. I can see that this patient stopped on day two and hasn't logged in in six days. At the top of the patient summary is the patient's phone number and email address.
At that point I can take action. I may want to just pick up the phone and say "Hi Mr. Patient, how are you, how is LACE® online going?" Or, I may want to have my front office assistant call the patient and book an appointment so that I can demonstrate LACE® through Sycle on my large flat screen monitor. Having access to this data gives the provider the flexibility of how they wish to follow up. It provides the information conveniently and in real-time, because it is all in Sycle, where the professional is working in all day.
SMAKA: In a way it reminds me of data logging. Data logging is great because it provides more information about the fitting, and for counseling. And, it provides another reason for a touch point with that patient who may be new with hearing aids, i.e., "I wanted to know how it's going with your hearing aids and the LACE® training".
LINDEMANN: I think that's an absolutely wonderful point, and that really gets into the key benefits of the LACE® online products. We talked about the benefits of the integration with Sycle, but at the end of the day what is LACE® online doing? It's teaching my patients how to optimize the benefits of the technology you just purchased.
You have new hearing aids to help you hear, and LACE® will teach you how to listen again. It's a clinical tool that is important in the context of patient care.
From a business perspective, good patient care is good business. If my patient learns how to listen again and is really excited that they can hear their grandkids and really excited that they don't have to turn the television up and annoy their next-door neighbors, they're probably not going to bring these hearing aids back for credit. Neurotone has data that show this is the case. These patients will also likely purchase again from you in five years when new technology is available.
LACE® is going to allow patients to fully realize the benefits of the gift of hearing. So the LACE® integration in Sycle is important from a patient care perspective, because that's really why LACE® is intended. But there's also that business component of reduced return rate with patients who complete program. Then there's the visibility within Sycle, so professionals can monitor and manage the LACE® training.
SMAKA: With the partnership of Sycle.net and Neurotone on the integration of LACE® into Sycle.net, should we expect to see any other changes in LACE® down the road?
SWEETOW: One of the things I'm hoping that with the cooperation of Sycle.net and Neurotone, and the fact that LACE® is now online, I think that the potential for making even more enhancements that were prohibitive due to cost and logistics can now be realized. There's so much that could be done because of the online structure - such as adding new training videos, uploading foreign language material, or developing an online patient forum, etc. - that this could possibly be just the beginning of some exciting projects moving forward.
LINDEMANN: At Sycle, when we finish a product, and even when we're in the middle of building the first phase of a product, we're already thinking about phase two. This type of thinking allows us to be creative throughout the entire lifecycle of developing a product. So we already have some exciting advancements on the way for the integration.
SMAKA: That's great, I love hearing that. It just seems like everything just gets tighter and more integrated and easier.
LINDEMANN: Absolutely, and as you look at the generational shift of hearing aid users with Boomers now wearing hearing aids, you'll see that seamless care is what they expect. They don't want to be handed a big welcome kit with discs that they have to read and sort through. They just want to go home, turn on their iPad, iPhone, Android or tablet and start training, which is all now possible with LACE® online and the Sycle integration. The goal is eliminating more of those tasks that either involve paper, discs or are really old school, and incorporating them in the new technology.
SMAKA: Thanks, Kevin. Robert, any final words about LACE®?
SWEETOW: I think the most important thing is that, as I mentioned, while all audiologists recognize the importance of LACE® and other aural rehabilitation tools, there's still a lack of enthusiasm about actually utilizing them. Maybe that's because they do not see an immediate benefit, or maybe because they're not familiar with the evidence-based literature supporting it.
The Sycle.net integration has helped make LACE® a seamless part of professionals' workflow, and that is very important. I hope more professionals will convey the message to the patient that the whole purpose of LACE® training is not related to hearing or to the hearing aids. While it's part of the same process, the whole concept of listening is different than hearing, and you need both in order to really function best.
Audiologists need to be vigilant about staying up to date and keeping informed about programs like LACE® if we are really committed to practicing evidence-based care and achieving the best patient outcomes.
For more information, visit www.Sycle.net or the Sycle.net web channel on AudiologyOnline.
Sweetow, R. & Sabes, J.H. (2010). The Communication Confidence Profile: A vital, but overlooked subjective domain. Hearing Journal, 63(12), 17 -18,20,22,24.