of Work: The purpose of this study is to develop protocols for performance testing that can be used in the clinical setting and to determine the feasibility of routine performance testing in the outpatient clinic setting. A further purpose is to evaluate certain methods that will be necessary for a more definitive study of these measures in clinical practice. A long-term goal of research in this area is to evaluate whether the routine use of performance measures provides information not currently being ascertained in outpatient visits. How often does functional decline occur with no documentation in the clinical record that functional problems or an event related to functional decline has occurred? To study this area, it will be necessary to document subclinical decline in functioning. This is a situation in which decline in performance measures occurs at a time when there is lack of a clear-cut documented symptom, physical finding, or new diagnosis to explain the decline. Subclinical decline will be considered as not occurring in cases where symptoms, signs, or new diagnoses would be recognized by most physicians as events with a strong likelihood of associated physical decline. Examples of such cases include injurious falls, onset of congestive heart failure, and stroke. It is in cases where subclinical decline occurs that the performance measures have the greatest potential to provide unique and valuable information to the clinician. Methodologic work is being done to develop and test chart review procedures that can be used in the assessment of subclinical functional decline. Revised protocols are being assessed and most recent evaluations indicate good inter-rater reliability for the determination of subclinical decline. Patients in both the Kansas City VA Medical Center and a local HMO are currently being administered performance tests when they are seen for routine clinical care. They will receive repeated assessments at all clinic visits to identify those with functional decline, who will then be evaluated using the methods being developed for this study.
