Abstract
The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has developed online videos intended to provide training on the most commonly used physical examination measures for psoriasis and psoriatic arthritis (PsA). At the 2012 GRAPPA annual meeting, attendees were updated on the development, availability, use, and validation of these video modules. To date, 1300 users from 45 different countries have used the Psoriasis Area and Severity Index (PASI) module at least once. Results were presented from a recently completed study of pre- and post-video scoring of the PASI by experienced and naive physicians and patient assessors. Future modifications of the video collection were also discussed.
- PSORIASIS
- PSORIATIC ARTHRITIS
- PSORIASIS AREA AND SEVERITY INDEX
- ARTHRITIS ASSESSMENT
- ENTHESITIS ASSESSMENT
- SPONDYLITIS ASSESSMENT
A variety of disease severity measures are available to assess the clinical features and severity of psoriasis and psoriatic arthritis (PsA) in research and in clinical practice. Although there is reasonably good consensus on how some measures, such as the Psoriasis Area and Severity Index (PASI)1 or the tender and swollen joint counts, should be performed, accessible and standardized training modules are needed. Members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), in collaboration with KIT Digital (formerly Accela Communications; Southborough, MA, USA), created several online educational videos in 2010 for use by clinicians and researchers who desire training on physician-assessed psoriasis and PsA disease severity instruments. They have been particularly useful for those conducting clinical trials to train and certify clinician investigators whose physical examination techniques must be accurate and reliable. At the 2012 GRAPPA annual meeting in Stockholm, Sweden, an update was provided on the development and current use of these training modules.
The GRAPPA video project was started in 2009, and the rationale for the project and its progress were covered in depth in previous meetings2,3. Traditional psoriasis measures such as the PASI or physician global assessment (PGA) are subjective, relying on the evaluator’s assignment of plaque qualities such as erythema, induration, and scale. Through expert training, the GRAPPA videos help overcome the limitations of these instruments and provide exposure to both established and newer assessment tools.
In each instructional video, an expert in the field uses photographs and video footage to demonstrate the assessments on volunteer patients. Modules were developed in collaboration with KIT Digital and are streamed on the Internet, where GRAPPA members can access them at the GRAPPA website (http://grappanetwork.org/). Access is also available for pharmaceutical sponsors for individual study requirements3.
Currently available dermatologic assessment modules include the PASI1, combined with training in body surface area (BSA) using a handprint method (1 handprint = 1%)4; the Psoriasis Scalp Severity Index5; Physician Global Assessment (PGA) with both 5-point (0–4) and 6-point (0–5) scales6; the original and modified Nail Psoriasis Severity Index (NAPSI)7,8; the Palmoplantar Pustular Psoriasis Area and Severity Index (PPPASI)9; and the Total Plaque Severity Score (TPSS)10, which is intended for scoring target lesions. Rheumatology training modules include assessment of tender and swollen joints using the American College of Rheumatology criteria, Disease Activity Score, and other composite arthritis scores11; and evaluations of enthesitis and dactylitis. An axial disease module is in development12,13,14.
The prototype module (PASI/BSA) has been the most widely accessed; to date, over 1300 individuals have completed this 16.5-minute instructional video at least once. Details of the registration, navigation, and certification processes have been described3.
One study of the validity of the PASI training module has been completed. April Armstrong (Davis, CA, USA) presented results of an equivalency study comparing assessments performed by patients and PASI-naive physicians to the assessments of PASI-experienced dermatologists15. All participants (42 patients and 12 PASI-naive dermatologists or dermatology residents) provided PASI scores for 3 sets of patient photographs. Ten days later, they viewed the online video and again provided PASI scores for the same 3 sets. The PASI-naive physicians and patients exhibited improved accuracy in assigning total PASI scores for mild, moderate, and severe psoriasis, compared to the criterion standard scores of the PASI-experienced dermatologists. These results suggest that a video-based online platform is effective at disseminating standardized training and that it could be a useful tool for patient self-assessment as well.
In summary, the GRAPPA training modules appear to be well regarded by clinicians, investigators, and industry sponsors, especially for baseline standardized education. As noted in previous updates, improvements are needed, including additional patient examples to increase the range of disease severity and of skin types; translation or subtitling in languages other than English (efforts are under way for Spanish and Portuguese translations); and additional modules demonstrating the use of new instruments in development, such as an inverse psoriasis assessment tool. It is also possible that groups interested in building consensus for other outcome measures could use the video modules to vote for their choices.
