The EUSTAR model for teaching and implementing the modified Rodnan skin score in systemic sclerosis

Objective: To evaluate the ability to teach scleroderma experts and young rheumatologists to perform the modified Rodnan skin score test. Methods: Three international "teaching courses for teachers'' were conducted with 6 - 9 experts who performed 3 - 9 skin score tests each. In addition, an international course for 90 young rheumatologists, in which 18 patients with systemic sclerosis ( SSc) participated, was also organised. Finally, a local repeated training course for 5 - 9 rheumatologists was performed, in which 6 - 7 patients with SSc participated. Results: When 6 - 9 scleroderma specialists investigated the patients, the intraclass correlation coefficient ( ICC) showed "good'' to "excellent'' values ( 0.865 and 0.710, respectively). When 90 young rheumatologists were involved in one teaching course, the coefficient of variation ( CV) was relatively satisfactory ( 35%) owing to the high number of investigators, and with a considerable within- patient SD value of 5.4. Repeated teaching of 5 - 9 young rheumatologists in local courses clearly improved the consistency. The ICC increased from 0.496 to a "good'' level of 0.722. The within- patient SD values for intraobserver variability ranged between 2.5 and 2.9. The intraobserver CV was about 20%. Conclusions: This study strongly supports the need for standardisation among different centres when using skin scoring for clinical trials. The intraobserver variability and within- patient SD values can be significantly reduced by repeated teaching. For inexperienced rheumatologists, at least one repeated teaching course is needed.