Improving patient function: a randomized trial of functional disability screening

STUDY OBJECTIVES: To test whether a 34-item functional status questionnaire measuring physical, psychological, and social function can be used by physicians in practice to help improve their patients' outcomes. DESIGN: Prospective randomized trial. SETTING: Community internal medicine practices. PATIENTS: Five hundred and ten continuing patients with functional disabilities who saw their physicians at least four times a year. PHYSICIANS: Seventy-six UCLA clinical volunteer faculty who are internists in community office practices. INTERVENTIONS: Physicians and their patients were randomly assigned to the experimental or the control group. Experimental group physicians attended a 2-hour multimedia educational session and received four functional status reports on each of their study patients over a 1-year period. Control group physicians received no education and no functional status feedback. Control group and experimental group patients were tested for functional status with the functional status questionnaire every 4 months for 1 year. Both groups also completed monthly diaries that measured use of health services. Experimental group physicians answered an anonymous evaluation questionnaire at 6 months after study entry. MEASUREMENTS AND MAIN RESULTS: Forty-three percent of experimental group physicians reported that they had used the functional status questionnaire to change therapy. Ninety-five percent reported that it was useful and accurate. Patient diaries did not show any difference between experimental group patients and control group patients in number of medications used, visits to physicians or other health professionals, equipment purchased, diet, or exercise programs. There were no significant differences between experimental and control group patients at exit from the study on any functional status or health outcome measure. CONCLUSION: A more powerful intervention than a 2-hour educational session and the regular provision of functional status information is needed to help office-based internists improve patient outcomes.     

Improving patient quality of life with feedback to physicians about functional status

OBJECTIVE: To improve functional status among primary care patients. INTERVENTION: 1) Computer-generated feedback to physicians about the patient’s functional status, the patient’s self-reported “chief complaint,” and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians. DESIGN: Randomized controlled trial. SETTING: University primary care clinic. PARTICIPANTS: All 73 internal medicine houseofficers and 557 of their new primary care patients. MEASURES: 1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire (FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician attitude about whether internists should address functional status problems. RESULTS: Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those of the control group physicians (p<0.03). Limitations in social activities indicated as “due to health” decreased among the elderly (>70 years of age) individuals in the experimental group compared with the control group (p<0.03). The experimental group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p<0.001) and took more actions recommended by the feedback form (p<0.02). CONCLUSIONS: Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems, and can assist physicians in improving emotional well-being and social functioning among their patients. Supported by the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the authors and do not necessarily represent the views of the Sepulveda VA, UCLA, CSUF, Rand, or the Robert Wood Johnson Foundation.     

Promoting use of colorectal cancer screening tests

BACKGROUND: Colorectal cancer (CRC) screening is underutilized despite evidence that screening reduces mortality. OBJECTIVE: To assess the effect of an intervention targeting physicians and their patients on rates of CRC screening. DESIGN: A randomized clinical trial of community physicians and their patients. PARTICIPANTS: Ninety-four community primary care physicians randomly assigned to an intervention consisting of academic detailing and direct mailings to patients or a control group. Patients aged 50 to 79 years in the intervention group physicians received a letter from their physician, a brochure on CRC screening, and a packet of fecal occult blood test (FOBT) cards. MEASUREMENTS: After 1 year we measured receipt of the following: (1) FOBT in the past 2 years, (2) flexible sigmoidoscopy (SIG) or colonoscopy (COL) in the previous 5 years, and (3) any CRC screening. We report the percent change from baseline in both groups. RESULTS: 9,652 patients were enrolled for 2 years, and 3,732 patients were enrolled for 5 years. There was no increase in any CRC screening that occurred in the intervention group for patients enrolled for 2 years (12.7 increase vs 12.5%, P=.51). Similar results were seen for any CRC screening among patients enrolled for 5 years (9.7% increase vs 8.6%, P=.45). The only outcome on which the intervention had an effect was on patient rates of screening SIG (7.4% increase vs 4.4%, P<.01). CONCLUSION: With the exception of an increase in rates of SIG in the intervention group, the intervention had no effect on rates of CRC screening. Future interventions should assess innovative approaches to increase rates of CRC screening.     

Failure of physicians to recognize functional disability in ambulatory patients.

OBJECTIVE: To assess the ability of internists to identify functional disabilities reported by their patients. DESIGN: Comparison of responses by physicians and a random sample of their patients to a 12-item questionnaire about physical and social function. SETTING: A hospital-based internal medicine group practice in Boston, Massachusetts, and selected office-based internal medicine practices in Los Angeles, California. SUBJECTS: Five staff physicians, three general internal medicine fellows, and 34 internal medicine residents in the hospital-based practice and 178 of their patients. Seventy-six physicians in the office-based practices and 230 of their patients. MEASUREMENTS AND MAIN RESULTS: Physicians underestimated or failed to recognize 66% of disabilities reported by patients. Patient-reported disabilities were underestimated or unrecognized more often in the hospital-based practice than in the office-based practices (75% compared with 60%, P less than 0.05). Physicians overstated functional impairment in 21% of paired responses in which patients reported no disability. CONCLUSIONS: Physicians often underestimate or fail to recognize functional disabilities that are reported by their patients. They overstate functional impairment to a lesser degree. Because these discrepancies may adversely affect patient care and well-being, medical educators and clinicians should pay more attention to the assessment of patient function.     

Training physicians about smoking cessation

Study objective:To test the hypotheses that physicians in private practice who receive a continuing education program (entitled “Quit for Life”) about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients. Design:Randomized trial with blinded assessment of principal outcomes. Setting:Private practices of internal medicine and family practice. Subjects:Forty-four physicians randomly assigned to receive training (24) or serve as controls (20) and consecutive samples of smokers visiting each physician (19.6 patients per experimental and 22.3 per control physician). Interventions:Physicians received three hours of training about how to help smokers quit. Physicians and their office staffs were also given self-help booklets to distribute to smokers and were urged to use a system of stickers on charts as reminders to counsel smokers about quitting. Measurements and main results:Based on telephone interviews with patients, physicians in the experimental group were more likely to discuss smoking with patients who smoked (64% vs. 44%), spent more time counseling smokers about quitting (7.5 vs. 5.2 minutes), helped more smokers set dates to quit smoking (29% vs. 5% of smokers), gave out more self-help booklets (37% vs. 9%), and were more likely to make a follow-up appointment about quitting smoking (19% vs. 11% of those counseled) than physicians in the control group. One year later, the rates of biochemically confirmed, long-term (≥9 months) abstinence from smoking were similar among patients in the experimental (3.2%) and control (2.5%) groups (95% confidence interval for the 0.7% difference: −1.7 to +3.1%). Conclusions:The authors conclude that this continuing education program substantially changed the way physicians counseled smokers, but had little or no impact on rates of long-term smoking cessation among their patients. There is a need for more effective strategies to help physicians help their patients to quit smoking. Supported by Grant # CA38337 from the National Cancer Institute and by the Henry J. Kaiser Foundation Faculty Fellowship in General Internal Medicine (SRC).     

Evaluation of a screening program for diabetic retinopathy in a primary care setting Dodia (Dépistage ophtalmologique du diabète) study

OBJECTIVES: The aim of this observational study was to evaluate the screening for diabetic retinopathy (DR) using eye fundus photography taken by a nonmydriatic camera and transmitted trough the Internet to an ophthalmological reading centre, as compared to a dilated eye examination performed by an ophthalmologist. METHODS: A total of 456 and 426 diabetic patients were included by two different groups of primary care physicians (PCPs), 358 being screened with the non-mydriatic camera (experimental group) and 320 with dilated eye fundus exam (control group). RESULTS: The proportion of screened patients for whom PCPs received a screening report within the 6-month follow-up period was 74,1% for the experimental group and 71,5% for the control group. Screening for DR was negative in 77,6% of patients with eye fundus photographs vs 89,6% with dilated eye examination. DR was diagnosed in 62 patients (17,3%) with eye fundus photographs versus 31 with dilated eye examination (10,4%). Referral to an ophthalmologist was required in 59 reports of patients with photographs (16.5%), 23 of them due to high grade DR. Finally, the non-mydriatic camera was found of little inconvenience by patients. CONCLUSION: The telemedical approach to DR screening proved to be effective in providing primary care practitioners with information about their patient's eye status. This screening method allowed to identify patients requiring prompt referral to the ophthalmologist for further complete eye examination. In conclusion, this study provided successful results of DR screening using fundus photography in primary care patients, and strongly supports the need to further extend this screening program in a larger number of French sites.     

The Impact of Consumer-Directed Health Plans and Patient Socioeconomic Status on Physician Recommendations for Colorectal Cancer Screening

Background  Consumer-directed health plans are increasingly common, yet little is known about their impact on physician decision-making and preventive service use. Objective  To determine how patients’ deductible levels and socioeconomic status may affect primary care physicians’ recommendations for colorectal cancer screening. Design, Setting, and Participants  Screening recommendations were elicited using hypothetical vignettes from a national sample of 1,500 primary care physicians. Physicians were randomized to one of four vignettes describing a patient with either low or high socioeconomic status (SES) and either low- or high-deductible plan. Bivariate and multivariate analyses were used to examine how recommendations varied as a function of SES and deductible. Outcome Measures  Rates of recommendation for home fecal occult blood testing, sigmoidoscopy, colonoscopy, and inappropriate screening, defined as no screening or office-based fecal occult blood testing. Results  A total of 528 (49%) eligible physicians responded. Overall, 7.2% of physicians recommended inappropriate screening; 3.2% of patients with high SES in low-deductible plans received inappropriate screening recommendations and 11.4% of patients with low SES in high-deductible plans for an adjusted odds ratio of 0.22 (0.05–0.89). The odds of a colonoscopy recommendation were over ten times higher (AOR 11.46, 5.26–24.94) for patients with high SES in low-deductible plans compared to patients with low SES in high-deductible plans. Funds in medical savings accounts eliminated differences in inappropriate screening recommendations. Conclusions  Patient SES and deductible-level affect physician recommendations for preventive care. Coverage of preventive services and funds in medical savings accounts may help to mitigate the impact of high-deductibles and SES on inappropriate recommendations. Craig Evan Pollack and Giridhar Mallya: The authors contributed equally to this publication.     

Decision making and counseling around mammography screening for women aged 80 or older

BACKGROUND: Despite uncertain benefit, many women over age 80 (oldest-old) receive screening mammography. OBJECTIVE: To explore decision-making and physician counseling of oldest-old women around mammography screening. DESIGN: Qualitative research using in-depth semi-structured interviews. PARTICIPANTS: Twenty-three women aged 80 or older who received care at a large academic primary care practice (13 had undergone mammography screening in the past 2 years) and 16 physicians at the same center. APPROACH: We asked patients and physicians to describe factors influencing mammography screening decisions of oldest-old women. We asked physicians to describe their counseling about screening to the oldest-old. RESULTS: Patients and/or physicians identified the importance of physician influence, patient preferences, system factors, and social influences on screening decisions. Although physicians felt that patient’s health affected screening decisions, few patients felt that health mattered. Three types of elderly patients were identified: (1) women enthusiastic about screening mammography; (2) women opposed to screening mammography; and (3) women without a preference who followed their physician’s recommendation. However, physician counseling about mammography screening to elderly women varies; some individualize discussions; others encourage screening; few discourage screening. Physicians report that discussions about stopping screening can be uncomfortable and time consuming. Physicians suggest that more data could facilitate these discussions. CONCLUSIONS: Some oldest-old women have strong opinions about screening mammography while others are influenced by physicians. Discussions about stopping screening are challenging for physicians. More data about the benefits and risks of mammography screening for women aged 80 or older could inform patients and improve provider counseling to lead to more rational use of mammography. The authors have no conflicts of interest to declare. This paper was presented in part at the 2005 National Meeting of the Society of General Internal Medicine, May 13, 2005, New Orleans, LA. Grant support was obtained from the National Research Service Award from the National Cancer Institute (1 F32 CA110424-01).     

Psychiatric screening in the emergency department: its effect on physician behavior

The purpose of our prospective, controlled study was to determine whether providing the results of a psychiatric screening instrument, the General Health Questionnaire (GHQ), to emergency physicians would result in a change in the detection and management of patients with psychosocial problems. Five hundred ninety-nine emergency department patients were enrolled, 242 in the control and 357 in the intervention group. Noncritical patients, selected by presenting complaint, were given the GHQ to complete before physician evaluation; those whose GHQ scores were high (10 or higher) were identified as having a greater likelihood of having psychosocial problems. During the intervention phase, physicians were provided the patient's GHQ score before beginning their evaluation, as well as a specific mechanism for psychosocial referral. A significantly greater proportion of patients with high GHQ scores in both study groups were judged by physicians to have a psychiatric problem (P less than .0001). During the intervention phase, patients with high scores more frequently were assigned a psychiatric diagnosis (14.1% vs 7.7%) and received psychosocial referral (36.1% vs 5.7%). However, only the latter difference was statistically significant (P less than .0001). The majority (85.7%) of patients offered psychosocial referral accepted their referral. There was no difference in the number of laboratory tests ordered or medical/surgical referrals requested between patients in the control or intervention groups with high scores. Therefore, providing GHQ results to emergency physicians led to more frequent psychiatric diagnoses and psychosocial referrals of patients with high GHQ scores but did not alter their medical management.     

Cancer screening in the elderly

Cancer screening in the elderly presents several unique challenges. There are no prospective trials of any cancer screening exam that have conclusively demonstrated efficacy in this age group. Any assessment of cancer screening in the elderly must include measuring an improvement in quality of life and functional status as well as decreased mortality from early cancer detection. Older patients usually prefer improved quality over quantity of life; they may be less interested in a trade-off of months or years of life in exchange for the side effects of cancer treatment. The elderly may need more home assistance during the treatment of the detected cancers; physicians should arrange for this. All of these variables must be included in studies of cancer screening in the elderly; the need for these studies is great. The following recommendations are probably the most reasonable in view of the currently inadequate knowledge base. Screening for breast cancer has demonstrated efficacy, with growing evidence for a cumulative effect from monthly breast self-examination, yearly breast examination by a physician, and yearly or biennial mammography. There may be no need to screen for cervical cancer in women after age 65 who have had regular Pap smear screening; however, older women who have never had Pap smears should have regular Pap smears for several years. Finally, because of the high frequency of colorectal and prostate cancers in the elderly, physicians should probably perform yearly rectal examinations with stool guaiac and regular sigmoidoscopy in this age group until definitive data support continuing or discontinuing these screening examinations. Physicians should educate their elderly patients to the importance of regular cancer screening and cancer risk-factor modification and should offer cancer screening examinations and counseling to elderly patients on a regularly scheduled basis.     

Reduction of job loss in persons with rheumatic diseases receiving vocational rehabilitation: a randomized controlled trial

OBJECTIVE: Job loss is a major consequence of rheumatic diseases, and clinicians may refer patients to vocational rehabilitation for help. When provided after job loss, the impact of vocational rehabilitation is short term. This randomized controlled trial with 48 months of followup was undertaken to determine the efficacy of vocational rehabilitation provided to persons with rheumatic diseases while they are still employed, but at risk for job loss. METHODS: A total of 242 patients with rheumatic diseases residing in Massachusetts were recruited through their rheumatologists for study. Participants were randomly assigned to the experimental group (n = 122) or the control group (n = 120). Subjects in the experimental group received two 1.5-hour sessions of vocational rehabilitation; those in the control group received print materials about disability employment issues and resources by mail. The main outcome assessed was the time to first job loss. Job losses were defined as permanent disability, premature retirement, or a period of unemployment. All analyses were conducted on an intent-to-treat basis. RESULTS: Job loss was delayed in the experimental group compared with the control group (P = 0.03 by log rank test). After adjustment for confounders, participation in the experimental group was found to be protective against job loss (odds ratio 0.58 [95% confidence interval 0.34-0.99], P = 0.05 by pooled logistic regression). CONCLUSION: Vocational rehabilitation delivered to patients at risk for job loss, but while they were still employed, delayed job loss. Such an intervention has the potential to reduce the high indirect costs, as well as the personal impact, of rheumatic diseases.     

Expanding patient involvement in care. Effects on patient outcomes

An intervention was developed to increase patient involvement in care. Using a treatment algorithm as a guide, patients were helped to read their medical record and coached to ask questions and negotiate medical decisions with their physicians during a 20-minute session before their regularly scheduled visit. In a randomized controlled trial we compared this intervention with a standard educational session of equal length in a clinic for patients with ulcer disease. Six to eight weeks after the trial, patients in the experimental group reported fewer limitations in physical and role-related activities (p less than 0.05), preferred a more active role in medical decision-making, and were as satisfied with their care as the control group. Analysis of audiotapes of physician-patient interactions showed that patients in the experimental group were twice as effective as control patients in obtaining information from physicians (p less than 0.05). Results of the intervention included increased involvement in the interaction with the physician, fewer limitations imposed by the disease on patients' functional ability, and increased preference for active involvement in medical decision-making.     

Primary juvenile fibromyalgia. Psychological adjustment,family functioning,coping, and functional disability

Objectives. 1) To determine the importance of psychological adjustment and family functioning in primary juvenile fibromyalgia by assessing these factors in children with fibromyalgia and in their parents, compared with children with juvenile rheumatoid arthritis (JRA) and with pain-free control children and their parents. 2) To examine which of these factors predict functional disability. Methods. Fifteen children in each of the 3 study groups, and their parents, completed self-report questionnaires and pain diaries. A medical evaluation of each child was performed, including assessment of tender points by palpation and by dolorimetry. Results. All children in the fibromyalgia group met the Yunus and Masi criteria for fibromyalgia, and 11 met the American College of Rheumatology criteria. There were almost no significant group differences in the children's or parents' psychological adjustment, ratings of family functioning, or coping strategies. Significant group differences in functional disability, pain, fatigue, tender point threshold, and control point tolerance were found. A number of the psychological adjustment, pain, fatigue, and coping variables were significantly associated with functional disability. Conclusion. The notion that fibromyalgia is a psychogenic condition is not supported by these results. Fibromyalgia is associated with disability of a magnitude comparable to that of other chronic pain conditions. Disability among children with fibromyalgia or JRA is a function of the children's psychological adjustment and physical state, and of the parents' physical state and method of coping with pain.     

Brief report: Physician discomfort and variability with disability assessments

BACKGROUND: Completing a disability assessment is a common physician task; yet, little formal training is available. OBJECTIVE: To assess physician comfort with disability assessments, and evaluate their consistency. DESIGN: We conducted 2 separate surveys. The "Comfort" survey asked physicians to rate their comfort (1 = very uncomfortable to 10 = very comfortable) with 12 potentially uncomfortable tasks, including disability assessment. The second survey described 2 different patients requesting disability assessment, 1 with acute and the other with chronic back pain; participants assigned each a level of disability. PARTICIPANTS: Resident and staff physicians at an urban county hospital. RESULTS: For 54 physicians returning "Comfort" surveys, disability assessment had the lowest average comfort rating (4.3, SD 1.9) compared with all other tasks (mean ratings ranged from 4.8 to 8.0). For the 73 physicians returning the "Disability Cases" survey, 88% found Case 1 qualified for limited employment, but varied on the types of limitations imposed. For Case 2, 39% assigned no disability, 39% limited employment, and 22% full disability. CONCLUSIONS: Our pilot studies support the hypothesis that physicians are not comfortable with disability assessment, and their assessments can be highly variable. Physician discomfort and lack of training may contribute to variability in disability assessments.     

Suicidal ideation among urban medical outpatients

The prevalence of current suicidal ideation among urban primary care outpatients was assessed, and suicidal and non-suicidal patients were compared with regard to their demographic characteristics and their attitudes toward mental health screening. Twenty (3.3%) patients reported having thoughts of killing themselves. The patients who had suicidal ideation were significantly younger and more frequently divorced. Almost all (97.6%) of the patients indicated that their physicians should inquire about emotional health issues at some time, and the suicidal patients were nonsignificantly more likely to recommend inquiry about psychiatric symptoms at every visit (55.0% vs 37.0%, p<0.11). Only half of the suicidal patients reported lifetime histories of mental health treatment. The majority (70.2%) of the patients believed that it would be easy to discuss mental health problems with their medical physicians. Among the patients who had previously received psychiatric treatment, the suicidal patients were nearly three times more likely to anticipate that it would be difficult or very difficult to talk to their physicians about psychiatric problems. In contrast, among the patients who had no history of mental health treatment, there was no association between suicidal ideation and anticipated discomfort in talking with their physicians about emotional health.     

Physicians' effectiveness in assessing risk for human immunodeficiency virus infection

An American Medical Association committee recently recommended that physicians routinely screen patients for behaviors that put patients at risk for human immunodeficiency virus infection, yet there is evidence that this screening does not occur routinely. Faculty, fellows, and residents at a teaching hospital in a midwestern state with a low prevalence of acquired immunodeficiency syndrome were surveyed regarding their experience in screening for human immunodeficiency virus, their training related to substance abuse and human sexuality, and their confidence and ease in addressing such topics with their patients. Results indicated that only 11% routinely screened patients for high-risk behaviors. While most physicians had received training in human sexuality, most had not received training in substance abuse screening. Those trained felt more confident in addressing substance abuse and human sexuality and felt more comfortable in caring for patients known to be infected with human immunodeficiency virus. A concerted effort to encourage human immunodeficiency virus risk assessment by physicians is needed. This should include training opportunities in screening and counseling patients about sexual activities and substance abuse.     

Effect of a geriatric consultation team on functional status of elderly hospitalized patients. A randomized, controlled clinical trial

STUDY OBJECTIVE: To evaluate the impact of a geriatric consultation team on the functional status of hospitalized elderly patients. DESIGN: Randomized controlled clinical trial. SETTING: University-affiliated referral Veterans Administration Medical Center. PATIENTS: One hundred and seventy-eight hospitalized elderly men 75 years or older admitted to medical, surgical, and psychiatry services, but excluding patients admitted to intensive care units. INTERVENTION: Eighty-eight intervention group patients received multidimensional evaluation by an interdisciplinary geriatric consultation team composed of a faculty geriatrician, geriatrics fellow, geriatric clinical nurse specialist, and a social worker trained in geriatrics. Results of the evaluation, including problem identification and recommendations, were given to the patients' physicians. Ninety control group patients received only usual care. MEASUREMENTS AND MAIN RESULTS: Intervention and control groups were comparable initially. The major outcome variable was the Index of Independence in the Activities of Daily Living (ADL) (Katz). Thirty-nine percent of the total study population was functionally independent on admission, 27% required assistance with one to three ADL, 22% required assistance with four to six ADL, and 12% were completely dependent. Many patients remained unchanged from admission to discharge: intervention group, 38%; control group, 39%. In the intervention group, 34% improved and 28% declined; in the control group, 26% improved and 36% declined. Although these changes reflected a trend toward greater improvement in the intervention group, the results were not statistically significant. CONCLUSIONS: Among elderly patients entering an acute-care hospital, approximately 60% had some degree of, and one third had serious functional disability. Such patients are at risk for further decline during hospitalization. A geriatric consultation team was unable to alter the degree of functional decline. Geriatric units or consultation teams may have to offer direct preventive or restorative services in addition to advice if improvements are to be made.     

Activities of daily living function and disability in older adults in a randomized trial of the health enhancement program

BACKGROUND: Disability in basic activities of daily living (ADLs) implies a loss of independence and increases the risk for hospitalization, nursing home admission, and death. Little is known about ways by which ADL disability can be prevented or reversed. The authors evaluated the efficacy of the Health Enhancement Program in preventing and reducing ADL disability in community-dwelling older adults. METHODS: The authors analyzed data from a 12-month, randomized, single-blinded, controlled trial of a disability prevention, chronic disease self-management program involving 201 adults aged 70 years and older that was conducted from February 1995 to June 1996 at a senior center in western Washington state. Activities of daily living disability incidence, improvement, and worsening were assessed using intention-to-treat methods. RESULTS: The cumulative incidence of ADL disability among those who were not ADL disabled at baseline (n = 56 in the intervention group, n = 57 in the control group) was modestly lower in the intervention group than in the control group at 12 months (14.3% vs 21.3%, p = .466). Cumulative improvement in ADL function among those who reported any ADL disability at baseline (n = 41 in the intervention group, n = 43 in the control group) was greater in the intervention group at 12 months (80.5% vs 46.5%, p = .026). The likelihood for ADL improvement was greater in the intervention group compared with controls at 12 months (adjusted hazard ratio, 1.84; 95% confidence interval, 1.05 to 3.22; p = .020). Cumulative worsening of ADL function was slightly lower in the intervention group at 12 months (18.6% vs 26.5%, p = .237). Intervention participants tended to be at lower risk for ADL worsening (adjusted hazard ratio, 0.71; 95% confidence interval, 0.38 to 1.30; p = .266) compared with control participants. CONCLUSION: The Health Enhancement Program intervention led to improved ADL functioning in those who were disabled initially and thereby offers a promising strategy for limiting or reversing functional decline in disabled elderly persons.