Robert M Arnold

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (377)1784.73 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Depressive symptoms and pain are common in patients receiving chronic hemodialysis, yet their effect on dialysis adherence, health resource utilization, and mortality is not fully understood. This study sought to characterize the longitudinal associations of these symptoms with dialysis adherence, emergency department (ED) visits, hospitalizations, and mortality.
    Clinical journal of the American Society of Nephrology : CJASN. 07/2014;
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    ABSTRACT: Objectives. We sought to test reliability of two approaches to classify adverse events (AEs) associated with helicopter EMS (HEMS) transport. Methods. The first approach for AE classification involved flight nurses and paramedics (RN/Medics) and mid-career emergency physicians (MC-EMPs) independently reviewing 50 randomly selected HEMS medical records. The second approach involved RN/Medics and MC-EMPs meeting as a group to openly discuss 20 additional medical records and reach consensus-based AE decision. We compared all AE decisions to a reference criterion based on the decision of three senior emergency physicians (Sr-EMPs). We designed a study to detect an improvement in agreement (reliability) from fair (kappa = 0.2) to moderate (kappa = 0.5). We calculated sensitivity, specificity, percent agreement, and positive and negative predictive values (PPV/NPV). Results. For the independent reviews, the Sr-EMP group identified 26 AEs while individual clinician reviewers identified between 19 and 50 AEs. Agreement on the presence/absence of an AE between Sr-EMPs and three MC-EMPs ranged from κ = 0.20 to κ = 0.25. Agreement between Sr-EMPs and three RN/Medics ranged from κ = 0.11 to κ = 0.19. For the consensus/open-discussion approach, the Sr-EMPs identified 13 AEs, the MC-EMP group identified 18 AEs, and RN/medic group identified 36 AEs. Agreement between Sr-EMPs and MC-EMP group was (κ = 0.30 95%CI −0.12, 0.72), whereas agreement between Sr-EMPs and RN/medic group was (κ = 0.40 95%CI 0.01, 0.79). Agreement between all three groups was fair (κ = 0.33, 95%CI 0.06, 0.66). Percent agreement (58–68%) and NPV (63–76%) was moderately dissimilar between clinicians, while sensitivity (25–80%), specificity (43–97%), and PPV (48–83%) varied. Conclusions. We identified a higher level of agreement/reliability in AE decisions utilizing a consensus-based approach for review rather than independent reviews.
    Prehospital Emergency Care 05/2014; · 1.86 Impact Factor
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    ABSTRACT: Although critics have expressed concerns about cancer center advertising, analyses of the content of these advertisements are lacking.
    Annals of internal medicine 05/2014; · 13.98 Impact Factor
  • Yael Schenker, Douglas B White, Robert M Arnold
    JAMA Internal Medicine 05/2014; · 13.25 Impact Factor
  • Julie W Childers, Linda A King, Robert M Arnold
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    ABSTRACT: Objectives:To describe the prevalence of chronic pain and the risk of opioid misuse in a palliative care clinic. We reviewed patient records for 6 months for source of pain, treatment status, opioid misuse risk (Cut down, Annoyed, Guilty, and Eye-opener [CAGE] and Screener and Opioid Assessment for Patients with Pain version 1.0-Short Form [SOAPP-SF] scores), and urine drug screens. Of 323 patients, 91% had cancer, 56% undergoing cancer treatment, while 28% had no evidence of disease. Eighty-six (27%) patients had noncancer pain. In all, 46% of new patients had positive scores on the SOAPP-SF and 15% had a positive CAGE. Of the less than 5% of visits that included a urine drug screen, 56% had aberrant results.Conclusion:Chronic pain and indicators of opioid misuse risk were prevalent. Outpatient palliative care practices should develop policies to address these issues.
    The American journal of hospice & palliative care 04/2014;
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    ABSTRACT: Abstract Background: It is not known whether unmet palliative care needs are associated with an interest in palliative care services among patients with advanced cancer receiving ongoing oncology care. Objective: To assess the association between unmet palliative care needs and patient interest in subspecialty palliative care services. Design: Cross-sectional telephone survey. Subjects and setting: One hundred sixty-nine patients with advanced cancer receiving care from 20 oncologists at two academic cancer centers. Measurements: Surveys assessed palliative care needs in six domains. Patients were read a description of palliative care and then asked three questions about their current interest in subspecialty palliative care services (perceived need, likelihood of requesting, willingness to see if their oncologist recommended; all outcomes on 0-10 Likert scale). Results: The vast majority of patients described unmet palliative care needs, most commonly related to psychological/emotional distress (62%) and symptoms (62%). In fully adjusted models accounting for clustering by oncologist, unmet needs in these domains were associated with a higher perceived need for subspecialty palliative care services (psychological/emotional needs odds ratio [OR] 1.30; 95% confidence interval [CI] 1.06-1.58; p=0.01; symptom needs OR 1.27; 95% CI 1.01-1.60; p=0.04). There was no significant association between unmet needs and likelihood of requesting palliative care services. Willingness to see palliative care if oncologist recommended was high (mean 8.6/10, standard deviation [SD] 2). Conclusion: Patients with advanced cancer and unmet symptom and psychological/emotional needs perceive a high need for subspecialty palliative care services but may not request them. Efforts to increase appropriate use of subspecialty palliative care for cancer may require oncologist-initiated referrals.
    Journal of palliative medicine 03/2014; · 1.84 Impact Factor
  • Julie W Childers, Robert M Arnold
    Journal of palliative medicine 03/2014; · 1.84 Impact Factor
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    ABSTRACT: There is wide variation in end-of-life (EOL) intensive care unit (ICU) use among academic medical centers (AMCs). Our objective was to develop hypotheses regarding medical decision-making factors underlying this variation. This was a high-fidelity simulation experiment involving a critically and terminally ill elder, followed by a survey and debriefing cognitive interview and evaluated using triangulated quantitative-qualitative comparative analysis. The study was conducted in 2 AMCs in the same state and health care system with disparate EOL ICU use. Subjects were hospital-based physicians responsible for ICU admission decisions. Measurements included treatment plan, prognosis, diagnosis, qualitative case perceptions, and clinical reasoning. Sixty-seven of 111 (60%) eligible physicians agreed to participate; 48 (72%) could be scheduled. There were no significant between-AMC differences in 3-month prognosis or treatment plan, but there were systematic differences in perceptions of the case. Case perceptions at the low-intensity AMC seemed to be influenced by the absence of a do-not-resuscitate order in the context of norms of universal code status discussion and documentation upon admission, whereas case perceptions at the high-intensity AMC seemed to be influenced by the patient's known metastatic gastric cancer in the context of norms of oncologists' avoiding code status discussions. In this simulation study of 2 AMCs, hospital-based physicians had different perceptions of an identical case. We hypothesize that different advance care planning norms may have influenced their decision-making heuristics.
    Medical Decision Making 03/2014; · 2.89 Impact Factor
  • Yael Schenker, Robert M Arnold, Alex John London
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    ABSTRACT: Advertising by health care institutions has increased steadily in recent years. While direct-to-consumer prescription drug advertising is subject to unique oversight by the Federal Drug Administration, advertisements for health care services are regulated by the Federal Trade Commission and treated no differently from advertisements for consumer goods. In this article, we argue that decisions about pursuing health care services are distinguished by informational asymmetries, high stakes, and patient vulnerabilities, grounding fiduciary responsibilities on the part of health care providers and health care institutions. Using examples, we illustrate how common advertising techniques may mislead patients and compromise fiduciary relationships, thereby posing ethical risks to patients, providers, health care institutions, and society. We conclude by proposing that these risks justify new standards for advertising when considered as part of the moral obligation of health care institutions and suggest that mechanisms currently in place to regulate advertising for prescription pharmaceuticals should be applied to advertising for health care services more broadly.
    The American Journal of Bioethics 03/2014; 14(3):34-43. · 4.00 Impact Factor
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    ABSTRACT: Objective: Surrogates involved in decisions to limit life-sustaining treatment for a loved one in the intensive care unit (ICU) are at increased risk for adverse psychological outcomes that can last for months to years after the ICU experience. Post-ICU interventions to reduce surrogate distress have not yet been developed. We sought to (1) describe a conceptual framework underlying the beneficial mental health effects of storytelling, and (2) present formative work developing a storytelling intervention to reduce distress for recently bereaved surrogates. Method: An interdisciplinary team conceived the idea for a storytelling intervention based on evidence from narrative theory that storytelling reduces distress from traumatic events through emotional disclosure, cognitive processing, and social connection. We developed an initial storytelling guide based on this theory and the clinical perspectives of team members. We then conducted a case series with recently bereaved surrogates to iteratively test and modify the guide. Results: The storytelling guide covered three key domains of the surrogate's experience of the patient's illness and death: antecedents, ICU experience, and aftermath. The facilitator focused on the parts of a story that appeared to generate strong emotions and used nonjudgmental statements to attend to these emotions. Between September 2012 and May 2013, we identified 28 eligible surrogates from a medical ICU and consented 20 for medical record review and recontact; 10 became eligible, of whom 6 consented and completed the storytelling intervention. The single-session storytelling intervention lasted from 40 to 92 minutes. All storytelling participants endorsed the intervention as acceptable, and five of six reported it as helpful. Significance of Results: Surrogate storytelling is an innovative and acceptable post-ICU intervention for recently bereaved surrogates and should be evaluated further.
    Palliative and Supportive Care 02/2014; · 0.98 Impact Factor
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    ABSTRACT: Most studies have assessed conflict between clinicians and surrogate decision makers in ICUs from only clinicians' perspectives. It is unknown if surrogates' perceptions differ from clinicians'. We sought to determine the degree of agreement between physicians and surrogates about conflict and to identify predictors of physician-surrogate conflict. Prospective cohort study. Four ICUs of two hospitals in San Francisco, California. Two hundred and thirty surrogate decision makers and 100 physicians of 175 critically ill patients. Questionnaires addressing participants' perceptions of whether there was physician-surrogate conflict, as well as attitudes and preferences about clinician-surrogate communication; κ scores to quantify physician-surrogate concordance about the presence of conflict; and hierarchical multivariate modeling to determine predictors of conflict. Either the physician or surrogate identified conflict in 63% of cases. Physicians were less likely to perceive conflict than surrogates (27.8% vs 42.3%; p = 0.007). Agreement between physicians and surrogates about conflict was poor (κ = 0.14). Multivariable analysis with surrogate-assessed conflict as the outcome revealed that higher levels of surrogates' satisfaction with physicians' bedside manner were associated with lower odds of conflict (odds ratio, 0.75 per 1 point increase in satisfaction; 95% CI, 0.59-0.96). Multivariable analysis with physician-assessed conflict as the outcome revealed that the surrogate having felt discriminated against in the healthcare setting was associated with higher odds of conflict (odds ratio, 17.5; 95% CI, 1.6-190.1) while surrogates' satisfaction with physicians' bedside manner was associated with lower odds of conflict (0-10 scale; odds ratio, 0.76 per 1 point increase; 95% CI, 0.58-0.99). Conflict between physicians and surrogates is common in ICUs. There is little agreement between physicians and surrogates about whether physician-surrogate conflict has occurred. Further work is needed to develop reliable and valid methods to assess conflict. In the interim, future studies should assess conflict from the perspective of both clinicians and surrogates.
    Critical care medicine 02/2014; 42(2):328-35. · 6.37 Impact Factor
  • Robert Arnold, Anthony Back, James Tulsky
    Journal of Pain and Symptom Management 02/2014; 47(2):371–372. · 2.60 Impact Factor
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    Yael Schenker, Robert M. Arnold, Alex John London
    The American Journal of Bioethics 01/2014; 14(4). · 3.60 Impact Factor
  • Anthony Back, Robert M Arnold
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    ABSTRACT: Abstract The communication skills of noticing emotional cues and responding empathically are necessary but insufficient for some conversations about redefining goals of care. For some patients, an empathic response by a clinician is insufficient to move the conversation forward. We describe an expert approach that links empathy to action. In this approach, we outline (1) how affect provides a spotlight that illuminates what is important, (2) how empathy affords a way to connect with patients and families that engages deep values, (3) how clinicians can infer deep values through an associative process with patients, and (4) how clinicians can then design actions with patients and families and nurture their commitment to the actions.
    Journal of palliative medicine 12/2013; · 1.84 Impact Factor
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    ABSTRACT: Past studies that demonstrated that sexual dysfunction is common among women receiving chronic hemodialysis did not distinguish sexual dysfunction/difficulty from sexual inactivity. This study sought to differentiate these in order to elucidate the prevalence of true "sexual dysfunction" in this population. As part of a clinical trial of symptom management strategies in patients receiving chronic hemodialysis, female sexual function was prospectively assessed monthly for 6 months and quarterly thereafter using the Female Sexual Function Index, to which questions were added differentiating sexual dysfunction/difficulty from sexual inactivity. Beginning in month 7, patients were asked three questions about sexual activity, difficulty, and satisfaction monthly. Of the women enrolled in the clinical trial,125 participants completed 1721 assessments between 2009 and 2011. Scores on 574 of 643 (89%) quarterly Female Sexual Function Index assessments were consistent with sexual dysfunction, due largely to sexual inactivity, which was reported on 525 (82%) quarterly assessments. When reported (n=1663), the most frequently described reasons for sexual inactivity were lack of interest in sex (n=715; 43%) and lack of a partner (n=647; 39%), but rarely sexual difficulty (n=36; 2%). When reported (n=1582), women were moderately to very satisfied with their sexual life on 1020 (64%) assessments and on 513 of 671 (76%) assessments in which lack of interest was cited as a reason for sexual inactivity. Women indicated an interest in learning about the causes of and treatment for sexual dysfunction on just 5% of all assessments. Although many women receiving chronic hemodialysis are sexually inactive, few describe sexual difficulty. Most, including those with a lack of interest in sex, are satisfied with their sexual life and few wish to learn about treatment options. These findings suggest that true sexual dysfunction is uncommon in this population and that treatment opportunities are rare.
    Clinical Journal of the American Society of Nephrology 12/2013; · 5.07 Impact Factor
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    ABSTRACT: Lack of familiarity between teammates is linked to worsened safety in high risk settings. The emergency department (ED) is a high risk healthcare setting where unfamiliar teams are created by diversity in clinician shift schedules and flexibility in clinician movement across the department. We sought to characterise familiarity between clinician teammates in one urban teaching hospital ED over a 22 week study period. We used a retrospective study design of shift scheduling data to calculate the mean weekly hours of familiarity between teammates at the dyadic level, and the proportion of clinicians with a minimum of 2, 5, 10 and 20 h of familiarity at any given hour during the study period. Mean weekly hours of familiarity between ED clinician dyads was 2 h (SD 1.5). At any given hour over the study period, the proportions of clinicians with a minimum of 2, 5, 10 and 20 h of familiarity were 80%, 51%, 27% and 0.8%, respectively. In our study, few clinicians could be described as having a high level of familiarity with teammates. The limited familiarity between ED clinicians identified in this study may be a natural feature of ED care delivery in academic settings. We provide a template for measurement of ED team familiarity.
    Emergency Medicine Journal 12/2013; · 1.65 Impact Factor
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    ABSTRACT: Recent research and professional guidelines support expanded use of outpatient subspecialty palliative care in oncology, but provider referral practices vary widely. We sought to explore oncologist factors that influence referrals to outpatient palliative care. Multisite, qualitative interview study at three academic cancer centers in the United States with well-established palliative care clinics. Seventy-four medical oncologists participated in semistructured interviews between February and October 2012. The interview guide asked about experiences and decision making regarding outpatient palliative care use. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine themes related to palliative care referral decisions. We identified three main oncologist barriers to subspecialty palliative care referrals at sites with comprehensive palliative care clinics: persistent conceptions of palliative care as an alternative philosophy of care incompatible with cancer therapy, a predominant belief that providing palliative care is an integral part of the oncologist's role, and a lack of knowledge about locally available services. Participants described their views of subspecialty palliative care as evolving in response to increasing availability of services and positive referral experiences, but emphasized that views of palliative care as valuable in addition to standard oncology care were not universally shared by oncologists. Improving provision of palliative care in oncology will likely require efforts beyond increasing service availability. Raising awareness of ways in which subspecialty palliative care complements standard oncology care and developing ways for oncologists and palliative care physicians to collaborate and integrate their respective skills may help.
    Journal of Oncology Practice 12/2013;
  • Jane O Schell, Robert M Arnold
    Seminars in Dialysis 11/2013; · 2.25 Impact Factor
  • Anthony L Back, Robert M Arnold
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    ABSTRACT: Abstract The query, "Isn't there anything more you can do?" represents a classic informational question with an emotional subtext. In our previous work we have emphasized the value of noticing the emotional cue implicit in this question, and responding with an empathic statement. Yet responding explicitly to patients' emotions is not the best initial communication strategy for all patients. In this paper we discuss four different opening communication strategies-verbalize empathy, exchange information, contain chaos, respect searching-for patients who ask, "Isn't there anything more you can do?"
    Journal of palliative medicine 09/2013; · 1.84 Impact Factor
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    ABSTRACT: Abstract Introduction. We sought to create a valid framework for detecting adverse events (AEs) in the high-risk setting of helicopter emergency medical services (HEMS). Methods. We assembled a panel of 10 expert clinicians (n = 6 emergency medicine physicians and n = 4 prehospital nurses and flight paramedics) affiliated with a large multistate HEMS organization in the Northeast US. We used a modified Delphi technique to develop a framework for detecting AEs associated with the treatment of critically ill or injured patients. We used a widely applied measure, the content validity index (CVI), to quantify the validity of the framework's content. Results. The expert panel of 10 clinicians reached consensus on a common AE definition and four-step protocol/process for AE detection in HEMS. The consensus-based framework is composed of three main components: (1) a trigger tool, (2) a method for rating proximal cause, and (3) a method for rating AE severity. The CVI findings isolate components of the framework considered content valid. Conclusions. We demonstrate a standardized process for the development of a content-valid framework for AE detection. The framework is a model for the development of a method for AE identification in other settings, including ground-based EMS.
    Prehospital Emergency Care 09/2013; · 1.86 Impact Factor

Publication Stats

6k Citations
1,784.73 Total Impact Points


  • 1992–2014
    • University of Pittsburgh
      • • Section of Palliative Care and Medical Ethics
      • • Division of General Internal Medicine
      • • School of Medicine
      • • Department of Obstetrics, Gynecology and Reproductive Sciences
      • • Institute to Enhance Palliative Care
      Pittsburgh, Pennsylvania, United States
  • 2013
    • Geisinger Medical Center
      Danville, Pennsylvania, United States
  • 2012–2013
    • UPMC
      Pittsburgh, Pennsylvania, United States
  • 2005–2013
    • University of Washington Seattle
      • Department of Medicine
      Seattle, Washington, United States
    • Hennepin County Medical Center
      • Department of Emergency Medicine
      Minneapolis, MN, United States
    • Albert Einstein College of Medicine
      • Geriatrics
      New York City, NY, United States
    • University of Sydney
      • Centre for Medical Psychology and Evidence-based Decision-making (CeMPED)
      Sydney, New South Wales, Australia
    • Mercy Hospital Miami
      Miami, Florida, United States
    • National Cancer Institute (USA)
      • Division of Cancer Prevention
      Bethesda, MD, United States
    • Icahn School of Medicine at Mount Sinai
      Manhattan, New York, United States
  • 2011
    • Widener University
      United States
  • 2007–2011
    • Duke University Medical Center
      • • Department of Medicine
      • • Department of Community and Family Medicine
      • • Duke Comprehensive Cancer Center
      Durham, NC, United States
  • 2006–2011
    • Duke University
      • • School of Nursing
      • • Department of Medicine
      Durham, North Carolina, United States
    • National Institutes of Health
      • Division of Cancer Prevention
      Bethesda, MD, United States
  • 2005–2011
    • Massachusetts General Hospital
      • Department of Medicine
      Boston, Massachusetts, United States
  • 2004–2011
    • Dana-Farber Cancer Institute
      • • Department of Psychosocial Oncology and Palliative Care
      • • Department of Medical Oncology
      Boston, MA, United States
  • 2003–2011
    • University of California, San Francisco
      • • Veterans Affairs Medical Center
      • • Division of Hospital Medicine
      • • Division of General Internal Medicine
      San Francisco, California, United States
    • VA Puget Sound Health Care System
      Washington, Washington, D.C., United States
  • 1992–2011
    • Beth Israel Deaconess Medical Center
      • Department of Medicine
      Boston, Massachusetts, United States
  • 2010
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
  • 2008–2010
    • Oregon Health and Science University
      • Division of Hematology & Medical Oncology
      Portland, OR, United States
    • Medical College of Wisconsin
      • • Department of Surgery
      • • Palliative Care Center
      United States
    • University of Rochester
      • Center for Ethics, Humanities, and Palliative Care
      Rochester, NY, United States
  • 2009
    • University of North Carolina at Chapel Hill
      • School of Nursing
      North Carolina, United States
    • University of Pennsylvania
      • Center for Health Equity Research
      Philadelphia, PA, United States
    • Seattle Cancer Care Alliance
      Seattle, Washington, United States
  • 2007–2009
    • U.S. Department of Veterans Affairs
      • Center for Health Equity Research and Promotion (CHERP)
      Washington, D. C., DC, United States
  • 2004–2009
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2007–2008
    • University of California, Irvine
      Irvine, California, United States
  • 2006–2008
    • Fred Hutchinson Cancer Research Center
      Seattle, Washington, United States
  • 2001–2008
    • Case Western Reserve University
      • • Department of Bioethics
      • • MetroHealth Medical Center
      • • Center for Biomedical Ethics
      Cleveland, OH, United States
    • Case Western Reserve University School of Medicine
      Cleveland, Ohio, United States
  • 2003–2005
    • University of Virginia
      • Division of Maternal Fetal Medicine
      Charlottesville, Virginia, United States
  • 2002
    • New York Medical College
      New York City, New York, United States
  • 2000
    • Pennsylvania State University
      • Department of Humanities
      State College, PA, United States
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 1993–2000
    • University of Michigan
      • • Division of General Medicine
      • • Medical School
      Ann Arbor, MI, United States
    • Harvard University
      Cambridge, Massachusetts, United States
  • 1995
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States