We find that the degree of impairment of protein function by missense variants is predictable by comparative sequence analysis alone. The applicable range of impairment is not confined to binary predictions that distinguish normal from deleterious variants, but extends continuously from mild to severe effects. The accuracy of predictions is strongly dependent on sequence variation and is highest when diverse orthologs are available. High predictive accuracy is achieved by quantification of the physicochemical characteristics in each position of the protein, based on observed evolutionary variation. The strong relationship between physicochemical characteristics of a missense variant and impairment of protein function extends to human disease. By using four diverse proteins for which sufficient comparative sequence data are available, we show that grades of disease, or likelihood of developing cancer, correlate strongly with physicochemical constraint violation by causative amino acid variants.[Supplemental material is available online at www.genome.org. A Java executable of MAPP and documentation are freely available for download at http://mendel.stanford.edu/supplementarydata/stone_MAPP_2005.]Missense mutations that impair protein function may result in disease. For diseases caused by such deleterious mutations, a simple but plausible model presents itself: The type of disease is dependent on when and where the protein's function is required in the organism. Given the type of disease, its severity is likely determined by at least three parameters: (1) the degree to which the function of the protein is impaired by the missense mutation; (2) variants of other genes that modulate the effect of the major locus, also referred to as genetic background; and (3) the environment. We present here a predictive statistical framework for the first of these parameters, impairment of protein function by missense mutations.Our study was motivated by several observations relevant to protein structure, function, and evolution, and by previous studies that addressed the relationship between the nature of missense variants, impairment of protein function, and resulting disease ( In aggregate, these studies suggest that mutations in evolutionarily conserved sites tend to impair protein function and lead to disease. There is also weak evidence that protein impairment and disease severity are somewhat correlated with the physicochemical difference between the original amino acid and the missense variant. However, no transparent, quantitative relationship between evolutionary constraint, functional impairment, and disease severity has been described. We believe that there has been a methodological barrier to uncovering such a relationship.Our analysis rests on two complementary ideas: (1) that differences in standard physicochemical properties between the "wild-type" amino acid and the missense variant are the root cause of functional impairment; and (2) that evolutionary variation among orthologs in the affected position is a sample ...