Doing what’s right for patients demands a culture change

We are pleased to announce the dates of our 2013 Lown Conference:
From Avoidable Care to Right Care

For more information on the 2013 conference, please visit our website:
http://lowninstitute.org/project/2013-lown-conference/

———————————————————————————————————————–

Do what’s right for patients, and cost control will follow.

Until recently, the main framework for thinking about reform has been one of shortages and disparities. That has begun to shift as patients and providers become more aware of the problem of unnecessary or avoidable care. Efforts to improve care and control costs will not be successful unless policymakers, payers, providers, and patients address the problem of avoidable care.

Considerable uncertainty remains. How much care in the US is avoidable? Can we quantify its consequences, in terms of financial impact and harms? What factors drive overutilization and inappropriate medical services, how can we curb it, and do physicians have an ethical duty to do so?

 

2013 Lown Conference: From Avoidable Care to Right Care

This year’s Lown Conference, From Avoidable Care to Right Care, will take place on December 3-4, 2013 in Boston, MA.

The 2013 invitation only conference will gather clinicians, patient advocates, and civic leaders to deepen our mutual understanding of the cultural, scientific, and ethical issues surrounding the overuse of medical services.

Attendees will leave this meeting with priorities for addressing this pervasive problem, and collaborators who are prepared to begin building bridges to the right care in their communities.

Major themes at this year’s event:

  • fostering a new kind of conversation among clinicians, patients, and civil society
  • envisioning health and health care 25 years from now
  • the global epidemic of overuse

Speakers include:

  • Don Berwick, MD, MPH, Former Administrator, Centers for Medicare and Medicaid Services (invited)
  • Katy Butler, Author of Knocking on Heaven’s Door
  • Bernard Lown, MD, Professor Emeritus, Harvard School of Public Health; Senior Physician (ret.), Brigham and Women’s Hospital, Boston
  • Richard Smith, MD, Former Editor BMJ
  • Rabbi Richard Address, D.Min, Senior Rabbi, Congregation Mkor Shalom

Our working groups for Medical Education, Community Engagement, International Collaboration, and Setting the Research Agenda will convene for a working session on December 5, 2013 following the conference. If you are interested in participating on one of these working groups, please email us for more information at info@lowninstitute.org.

For more information on the conference, including how to register, please visit the Lown Institute website at www.lowninstitute.org.

Shannon Brownlee’s ethics panel introduction

Below is Shannon Brownlee’s introductory speech from the ‘What are the ethical issues’ panel.

Thank you all for being here today – distinguished panelists and participants.

I want to tell you a story. That’s what writers do, tell stories. It’s not my story, it is Diane Meier’s, and I hope I tell it correctly. She told it to me years ago, and it haunts still, which is why I want to relate it to you.

The patient was an elderly Hispanic man. He barely spoke English, and he was dying of lung cancer when Diane met him. Mr. S., as she calls him, had watched his wife succumb to lung cancer three years earlier. When he was diagnosed with the same disease, he wanted no part of the side effects his wife had gone through. He declined chemotherapy, radiation, and surgery, saying he wanted to die at home, surrounded by his family.

The hospital sent him home, but a few months later, Mr. S. was brought in to the emergency room by his grown children. He was delirious and suffering seizures from metastases in his brain. The hospital admitted him to the neurology department, where he was stabilized.

When Diane entered his room, she found a frail, emaciated man. He had a nasogastric feeding tube, and he was thrashing was in his bed, yelling unintelligibly, and pinned down in 4-point restraints.

Diane went to find the neurology resident in charge, and asked him what was going on. The resident told her that Mr. S. had pulled out his feeding tube repeatedly, and that was why he was in restraints. And then, the young doctor looked at Diane, with enormous distress in his eyes, and said, “ ‘If I don’t keep Mr. S. in restraints, he’ll die.’ ”

There’s a concept in the medical ethics literature called moral distress — it’s a description of how one feels when you know what is ethically appropriate, but you are unable to do what’s right because of obstacles that are inherent in the situation. Moral distress was first described in 1984 in a book on nursing ethics and the term is mostly used in relation to nurses, who often feel trapped between the doctor’s orders and the suffering of patients.

Obviously moral distress is not limited to nurses. Diane’s story about the dying man haunts me because there was suffering on both ends of the stethoscope. The story of Mr. S gave me some insight into clinicians’ struggles, and it a measure of compassion – a way to integrate my own conflicting feelings about the role clinicians play in the delivery of unnecessary care.

Here is the conflict. On the one hand, it was a physician who wrote the orders for Mr. S to be put in 4-point restraints. It is, after all, always a clinician who writes an order for an unnecessary drug, who performs an unneeded catheterization, who admits a patient to the ICU when what the patient really wants is to die at home.

On the other hand, many clinicians feel trapped in a system that often pushes them to do the wrong thing. A system that makes it easy to do harm. And just like that young neurology resident, they feel a terrible distress.

Clearly the prime directive of medicine, primum non nocere, which I think would sound a lot better if it were pronounced with an Italian accent, is inadequate to the task of helping clinicians perform the balancing act that is inherent in the practice of medicine. Of balancing the potential for harm from not doing enough, which is where thinking about medical ethics has tended to dwell, against the harm from doing too much.

This leads us to many questions, a few of which I’ll name here:

1.Why do we perceive errors of commission as lesser sins than errors of omission?

2. And why do we not consider it an error, or at least unethical, to fail to inform patients about the true costs, both financial and physical, of medical care, and its limitations?

3.
How can it be ethical to use a shiny, new, and often very expensive technology, like a robot, or a drug-eluting stent, or a new surgical technique, as a marketing tool to bring in paying customers? And how can we continue to use it without bothering to find out if it actually works?

I’ll stop there.

My request to this panel is the answer to an admittedly blunt question: Do we need a new medical ethic? Because clearly, just saying no to harm is not enough.

I won’t go into lengthy introductions. Please read this panel’s bios. Diane Meier, Howard Brody, and Jerry Hoffman are highly accomplished, recognized in their fields, but they are here today because they also have thought deeply about the meaning of professionalism. Howard Brody has the added distinction of being a bioethicist by training.

Jerry Hoffman will lead off with some overarching principles. Howard Brody will bring an ethicist’s perspective, and Diane Meier will bring us full circle to the this problem of moral distress.

The role of patients and families – Jessie Gruman

The Role of Patients and Families in Avoiding Avoidable Care
Jessie Gruman
www.cfah.org

The speakers and discussants at this Avoiding Avoidable Care Meeting have not attributed to patients and families a significant role in curbing unecessary care and overtreatment. Thank goodness.

Indeed, we have heard little about “consumers” and “empowered patients,” the benign, egalitarian words that are so often used to disguise shifts onto patients risks and responsibilities that rightfully belong to clinicians and institutions. While some of us will be able to shoulder those new responsibilities, many of us will not. We are sick, we lack the time and resources, the cognitive skills or the confidence to take them on. This means we will be an unreliable force in challenging the status quo in which avoidable care is so common.

Continue reading here

 

Co-opt ‘Do no harm’ to leverage culture change

Introduction:
Primum non nocere, or First, do no harm, has a curious place in medicine and culture. On the one hand, it is widely recognized, and sometimes celebrated as “the cardinal ethical principle sacred to medicine.”1 Simultaneously, it is often rejected by bioethicists as “inadequate”2, “confounding”3, and serviceable only by “inert nostrums.”4 Clearly, the phrase’s utility depends on its interpretation.5

Do no harm can be interpreted in a way that is especially valuable to the Avoiding Avoidable Care movement. This document introduces five points of supportive interpretation, and then offers a proposal to use do no harm to influence medical school culture.

1- It is a moral injunction to listen. Primum is alternately translated as “first” and “above all else.” Notions of primacy have been interpreted as invoking medicine as a “moral enterprise”. 5 Since the basic morality of medicine is to serve patient interests above those of the doctor, a moral physician cannot serve, and therefore may harm, a patient’s interests if he or she does not actively determine what those interests are. Rather than actively sought, these interests are often simply assumed at best, and dismissed, even compromised, at worst. Quite simply, if a physician does not know their patient’s interests, First, do no harm invokes an image of an unhurried physician who begins with the patient’s interests well before embarking down the road of testing, diagnosis, and treatment. Such a physician recognizes the temptation for even simple tests to turn into painful and expensive treatments that the patient never had, or even wanted investigated. Such a physician thereby adheres to the principles, if not the techniques, of shared decision-making and its concomitant reductions in overtreatment.6 In addition, as explicated by Bernard Lown,7 listening clarifies the motives behind this service of patient interest, thereby engendering trust. Essential to the enterprise of medicine, trusting patients are more likely to adhere to their medications, return for follow-up, persevere with physical therapy, pass up alternative healers, and prefer the advice of their doctor over the speculation of Google, all consistent with reducing overtreatment. Further, patient trust is essential for doctors to successfully resist the common perceptions that drive treatment: doing is better than not doing, knowledge is power, certainty is strength, and errors of commission are preferred to errors of omission [Steven Smith].

2- It emphasizes avoiding harm. Abjuring carelessness and malice, or the principle of non-maleficence, is so obvious that saying so is not saying much at all. However, there are several subtle implications of the specific need to avoid harm that are specifically related to overtreatment and that may be lost if not they are not stated. Drivers include physicians’ lack of evidence about which treatments and devices are truly effective, as well as a common inability to appraise existing evidence. Another is the fear of medical malpractice suits that spurs defensive medicine. Arguably the most powerful cause of overtreatment is that doctors are paid according to the amount of care they provide.8 Crucially, this last point illustrates the value of harm avoidance language rather than care promotion. On a simple reading, “providing care” can readily be used to rationalize overtreatment, and its attendant revenue. Pharmaceutical and device companies routinely disguise their profit motives behind a veneer of care, but rarely invoke an avoidance of harm in any way similar to Bernard Lown’s dictum: “Foremost, we did as much for the patient, and as little to the patient as possible.”

3- It addresses the culture. Conveniently, do no harm is a cultural fixture that can be used to address another cultural fixture, namely, the belief among well-meaning physicians that more care is better care. According to Steven Smith, such beliefs are so pervasive, so deeply embedded within our ethic of caring and duty to patients that they become “the air we breathe,” and paradoxically easy to miss. Do no harm, unlike duty to treat or even serve the interests of my patients, includes a specific reminder that almost all care has risks. The phrase may be uniquely suited to identifying such a fundamental assumption. As well-meaning doctors begin to root out this subtle cause of overtreatment, then more overt profit-driven causes will become all the more evident.

4- It unifies the profession. Do no harm is notable for its widespread recognition among physicians. Regardless of its origin and interpretation, Primum non nocere is to medicine what Semper fidelis is to the Marines and Be prepared is to the Boy Scouts. Accordingly, the phrase has value to the extent that it strengthens the unity of a profession widely perceived to be under siege. At a time when cynicism among the ranks is growing, when forces of government and corporations are encroaching on physician autonomy, and when public trust is waning, physicians are abandoning professional societies like the American Medical Association just when they most need to organize and collaborate.9 Do no harm can become a rallying cry, attracting both physicians in training and established doctors who pursued medicine from a moral calling, but may have since lost faith. By offering a core value, one that harkens back to the roots of medicine, as a remedy for today’s dire health care situation may re-engage members with the profession’s mission.

5- It renews public trust. Since do no harm is so widely recognized by the public, using it to brand the avoidable care movement may be an effective strategy to counter the vast marketing machine of pharmaceutical companies, hospitals, and other health care corporations as they triumphantly tout the latest and greatest treatments. The phrase’s humble tone rebrands the mindful physician who listens and restrains inappropriate treatment as a paragon of trustworthiness, all the while carrying an attendant rejection of trust that is based on action. Finally, since very few market mechanisms are incentivized to promote the mission of avoiding avoidable care, co-opting the most famous line in medicine is an effective way to get the word out.

Proposal: Avoiding Avoidable Care, as a movement, co-opts First, do no harm and outlines an interpretation of the phrase’s meaning specific to the aims of the movement, a condensed version of the above. It then approaches the Arthur P. Gold Foundation, sponsor of the Gold Humanism Society and the White Coat Ceremony, in which almost every medical student participates at the start of medical school. The movement requests the inclusion of a First, do no harm campaign within the Gold Humanism Society’s White Coat Ceremony. Since oath taking is a requirement of this ceremony, including do no harm is consistent. The movement could also create a pin, similar in fashion to the Gold Foundation pin that is distributed at the White Coat Ceremony. Students would affix this do no harm pin to their lapels, as a sign of their mindfulness of overtreatment. Central to this campaign would be an emphasis on listening. Specifically, students would be encouraged to query patients about their interests and goals as something akin to the fifth vital sign, whereby it is sought from every encounter. By affixing a moral spotlight on listening, students would be charged to advocate and innovate methods to increase the length and effectiveness of patient encounters. Thereby, as the Movement develops guidelines and best practices for avoiding avoidable care, this charge can become a hook with which to publicize these developments to students themselves, thereby obviating the need to negotiate with the medical schools to incorporate this material into curricula.

Conclusion: Do no harm does not specifically speak to all aspects of Avoiding Avoidable Care. Specifically, interpreting it to comment on the need in some cases to perform care that is being neglected is tenuous. However, the phrases near universal recognition, moral invocation, negative language, and humbling spirit outshine its liabilities in interpretation and comprehensiveness. Admittedly, co-opting the phrase is more about leveraging its spirit than in creating the ideal slogan or tag line. However, an essential role of any movement is to capture the hearts and minds of participants. Do no harm is already in their minds, and by showcasing it at formative periods in physician training, it can capture their hearts. Since much has been made of the limitations and failures of medical training to address overtreatment, do no harm offers an easy way to redress the dwindling patient focus in medical schools and residencies.

-Aaron Stupple
April 29, 2012

 

References:

1. McGarrv L, Chodoff P. The ethics of involuntary hospitalization. In: Bloch S, Chodoff P, eds. Psychiatric Ethics. Oxford: Oxford University Press, 1981:217.

2. Smith C. Origin and Uses of Primum Non Nocere−−Above All, Do No Harm! Journal if Clinical Pharmacology. 2005 45: 371

3. Caelleigh AS. Cover note: medicines and poisons. Academic Medicine. 1998;73:842.

4. Lasagna L. The Therapist and the Researcher. Science. 1967;158:246-247

5. Jonsen A. Do No Harm. Annals of Internal Medicine. 88:827-832. 1978.

6. Joosten E, DeFuentes-Merillas L, et al. Systematic Review of the Effects of Shared Decision-Making on Patient Satisfaction, Treatment Adherence and Health Status. Psychotherapy Psychosomatics 2008;77:219–226

7. Lown, B. Social Responsibility of Physicians. Address presented at Avoiding Avoidable Care Conference, Cambridge, MA. April 26, 2012.

8. Brownlee, S. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. Bloomsbury USA.

9. Wynia M. The Short History and Tenuous Future of Medical Professionalism: The Erosion of Medicine’s Social Contract. Perspectives in Biology and Medicine. Volume 51, Number 4, 2008

A Primary Care Perspective – Allan H. Goroll

Payment Reform for Achieving Reduction in Unnecessary Care
The Primary Care Perspective – Key Issues

 Allan H. Goroll, MD, MACP
Massachusetts General Hospital, Harvard Medical School

The predominant system for physician payment in the U.S., Medicare’s fee-for-service (FFS) RBRVS model as interpreted for CMS by the AMA’s RBRVS Update Committee [RUC], has had several adverse, counterproductive effects on primary care:

• Incented high volumes of short visits by paying only for face-to-face care and assigning a very low rate for evaluation and management services

• Compromised time for proper diagnosis, patient education, counseling, and care management/shared decision making (Ludmerer: “No Time to Heal”)

• Reduced the diagnostic confidence of primary physicians, who feel too rushed to make a firm diagnosis and who compensate by resorting to excessive test ordering and low thresholds for specialty referral both for patient safety and for reducing liability risk

• Discouraged prospective new medical graduates from going into primary care due to financial penalty ($3.5M lifetime pay disparity) and poor work environment (the “hamster wheel”), leading to a national work force crisis in primary care

• Depleted primary care practices of the capital needed to implement the teams and technology necessary to achieve current high-performance standards

Needed: Fundamental reform of payment for primary care, including

• Elimination of the “volume imperative,” (i.e., eliminating the predominance of FFS)

• Realignment of payment to support desired outcomes (e.g., achievement of desired Triple Aim goals); if comprehensive care is desired, pay should be comprehensive rather than piecemeal.

• Assuring sufficient financial resources for the necessary teams and technology essential to high-performance practice

• Paying for work that creates value beyond the face-to-face encounter, including payment for care management and population management

• Powerful, validated risk adjustment that protects against cherry-picking patients.

• Incentives for collaborative care with other providers

• Ability to negotiate payment within integrated systems of care to assure payment is proportional to risk and responsibility undertaken and consistent with overall goals

Managing Costs by Keeping Patients Healthy

HMOs–a bad word in health reform circles–flourished and then declined 20 years ago.  But were they entirely worthless?  Often they were bullies that took no patient or provider input into their decisions, and their cost control strategies could be brutal.  Their payment schemes to providers could cause unscrupulous doctors to skimp on care, but they did bend the cost curve for a few years.

Their best feature was that their payment schemes did address overutilization.  This had the potential to save lives and reduce morbidity.  Nothing good can come to a patient who is subjected to a test or procedure that he doesn’t really need, and a great deal of risk comes with every medical intervention.  I see countless instances of overutilization every day: repair of fractures that don’t really need it, shoulder and knee scopes for vague or non-existent indications, MRIs ordered for pain without any physical findings.  Our current reimbursement schemes reward all of this.

If we knew then what we know now regarding patient satisfaction, physician strategies to improve patient outcomes, the importance of good communication and physician empathy, would the HMO payment model have had more success?  Could we have kept patients satisfied, feeling well cared for, and been given good care while eliminating the financial incentives for dangerous overutilization?  What if HMOs had understood the precepts of patient centered medicine as we currently understand it.  Could primary care doctors have told their patients “no” without causing a backlash?

Now, I’m not suggesting that we return to HMOs, but alternative payment strategies that deliver just the care that patients really need can succeed so long as they are coupled with doctors practicing patient centered care.  Office visits, especially to primary care docs, will need to be better reimbursed to make this model attractive to general practitioners, but HMOs floundered primarily due to poor patient satisfaction rates, and we know enough now to manage costs better and keep our patients healthy and happy with their care.

Commentary on Payment Mechanisms – Dolores Mitchell


Dolores Mitchell, Executive Director, Group Insurance Commission

Purchasers are under enormous pressure to reduce health care costs that increase the cost of their products and services, making companies non competitive and wages stagnant. Purchasers also lack the ability to affect overuse except with tools that often just pass the rising costs to consumers. Utilization review mechanisms breed resentment from employees as well as providers and are only marginally effective. Criticizing doctors or hospitals sis considered taboo,particularly in areas where the medical/pharmaceutical/medical device industries create jobs, even if they have a negative effect on job growth in other sectors of the economy. Purchasers welcome leadership in addressing issues of overuse by physician organizations such as the IOM, THE ABIM and the Lown Foundation.

RESTRICTING COVERAGE WITH DESIGNED DELAYS FOR RIGOROUS EVALUATION

from Malcolm Maclure, Prof & BC Chair in Patient Safety, University of British Columbia

I have one suggestion based on experience in British Columbia: when restrictions on coverage must be implemented, use design delays (staggered implementation.)

Ideally these would be randomized control groups, but controlled time series designs, especially with matching, are almost as rigorous as RCTs in my experience, and institutionally they seem to be more feasible.

I was inspired by my interview with Tom Chalmers almost 20 years ago, to advocate within the British Columbia Ministry of Health for control groups to be used when the public drug plan (‘PharmaCare’) introduced restrictions on drug coverage. I call this approach ‘designed delays’ because delays are the norm, and ‘designed’ feels like adding orderliness to the process, whereas ‘randomized’ feels like adding chaos to a program that is already complex.

Chalmers told me he had urged the Veterans Health Administration to pair-match hospitals and randomly select one of each pair to be first with a new service while the other hospital was delayed as a control. Despite his close connections with the VHA, he thrice failed to convince the VHA to use designed delays — for Coronary Care Units, for CAT scans and for MRIs. He was very frustrated by the experience and stymied on how to routinize randomization.

In British Columbia, we now routinely implement prescribing education initiatives with randomized delays but our success in using designed delays for changes in drug coverage has been much more limited. Our main success in using designed delays was in 1999 when we partially restricted coverage of nebulized medications. It went so smoothly that the method of designed delays was endorsed for 2 other drug restriction policies (but the restrictions were never introduced for other reasons.)

In contrast, designed delays when ADDING coverage of a new medication seems to be much more difficult. The hope (or hype) that the new drug will yield better outcomes, makes delays unacceptable. On the other hand, SUBTRACTING a medication or service that is believed by many (but not everyone) to be of little value, is made easier by promising rigorous evaluation by use of delays controls.

The most vehement critic and the strongest proponent of the policy AGREED that randomized delay was a good idea. They were both convinced that rigorous evaluation would prove they were right. Commitment to rigorous evaluation thus instantly refuted the criticism that the government was only interested in cost control, not patient outcomes.

A university ethics committee had no difficulty with randomized delays of the restriction because it eventually would apply to everyone, unless the evaluation showed the restriction was harmful (in which case the drug plan director was committed to reassessing the policy.) In contrast, another ethics committee was critical of our proposal for delayed coverage of a NEW medication.

My hypothesis is that when a health organization is forced to restrict services (e.g. the UK National Health Service must cut 20 billion pounds in the next four years), there will be many opportunities to evaluate the balance of benefits versus harms of the restrictions by using delayed controls.

Although Tom Chalmers’s advice mostly fell on deaf ears during times of plenty, I predict his advice will become more appealing to decision makers as cost pressures increase.

(These comments are my own opinions and observations in my academic capacity as Chair in Patient Safety at UBC. That appointment includes my continuation half-time as Co-Director of Research and Evidence Development, an advisory role in the Pharmaceutical Services Division of the BC Ministry of Health. I wish to stress that my opinions are not to be interpreted as representing the Ministry’s positions on these matters.)

A new hip for an 87 year old: the surgeon’s Siren song

I saw an elder gent a month ago;  his hip pain was getting worse ….  He’d seen a surgeon.

“You’ll be out of the hospital and rehab, home in 3 weeks” the surgeon said.

“You’ll be doing nothing but rehab and exercises for 3 MONTHS;   you’ll be at limited power for six months;  it will be a year to be 95%” I said.

He came in today for a preop evaluation.  Even though he’s been out mowing his lawn and doing most of what he wants, he thinks surgery will make him “better.”  He has “good insurance” and has chosen to proceed.

I’m reasonably confident he will “do well” perioperatively but I’m dubious that he’ll be “better” in the long run.

– excerpt from this afternoon’s office hours

Ted Herwig MD, family physician

Teaching Appropriate Utilization in Medical School

To some extent appropriate utilization can be taught to senior medical students by committed physicians who are knowledgeable about the negative consequences of not avoiding avoidable care. Included among likely instructors would be primary care physicians, internists (including medical subspecialists), pediatricians, surgeons and radiologists.

A six week curriculum with both didactic lectures and case presentations could form the substrate for the course. But there would have to be involvement from other knowledgeable individuals in each medical school who would educate the students about the economic, sociological and public health issues intrinsic to the topic.

Where could the time be found? The fourth year of medical school is in many ways a wasteland, (pun intended). It is in large measure a waste of time with allotments of weeks to meaningless requirements often merely to allocate treasured hours to satisfy the special desires of powerful actors who can influence curriculum assignments. It is a waste of money – both for the hours spent without a sound education focus and most specifically for the long and costly interview process incurred by students as they seek internship and residency positions.

Why should a student travel around the country on his or her dime to interview at the home site of a prospective training site in accordance with schedules which serve the convenience of Program Directors? And these odysseys occur predominantly in December and January when travel is most difficult.

Why not change the process? Program Directors could evaluate the applicant without a visit to the medical center. For example, law school is also a three year commitment

(like many residencies). Site visits to them are not mandatory, let alone necessary. In truth, applicants to medical training programs for the most part are more interested in the environs of the hospital, (the neighborhood and the city) than the structural character of the hospital or its amenities. Such information can be gleaned by web site displays and other material most programs now readily provide.

Or for small and moderate sized internships and residencies, interviews could be held at one or two locations nationally so that all applicants and interviewers come together for one week or so allowing for multiple interactions in a short time. These visits are secured by lower cost and lessened time away for both students and Program Directors than by customary visits at the behest and convenience of potential hirers. Podiatry does this now. Why can’t residency programs in medical specialties do it as well?

The time freed up in December and January can then be made to accommodate an uninterrupted course of study at the home base. The curriculum could be focused and sustained, devoted to the important mission of educating students about the specifics of appropriate rather than excessive care which is too often a product of the sensibilities of contemporary American medical graduates.

2014 © Lown Cardiovascular Research Foundation | 21 Longwood Avenue Brookline, MA 02446 USA | P: 617-732-1318 | F: 617-277-0347 | Contact Us
cheap viagra
cheapest uk viagra
buy viagra without a perscription
buy viagra now
buy cheap viagra online july
buy lasix
buy viagra online au
cheap deal viagra
order viagra online in wisconsin
buy viagra locally
buy viagra online paypal vipps
viagra and discovery
buy softtabs viagra
cheap deal deal pill viagra
cheap generic online viagra
purchase levitra online
buy nexium
order generic viagra online
cheap cheap discount sale viagra
cheap gerneric viagra
buy cailis viagra singapore
buy discount online viagra
Buy viagra Baltimore
buy discount price sale viagra viagra
buy online viagra
cheap generic viagra no script
Buy viagra Louisville
order viagra cheap
Buy viagra Portland
buy no online prescription viagra
buy paxil online
buy in online uk viagra
buy viagra online uk
buy buying sale viagra
cheap generic viagra substitute
cheap viagra discount viagra buy viagra
Buy viagra Columbus
viagra and coupon
Buy viagra Philadelphia
Buy viagra Newark
buy viagra cheap online
buy viagra free on internet
cheap discount cialis
Buy viagra Modesto
buy viagra overnight
cheapest online viagra
buy viagra over the counter us
cheap generic viagra overnight delivery
buy viagra cheapest best prices online
buy viagra online without prescription
viagra buying online
order viagra online uk
cheapest site viagra
cheap viagra online a href
buy now viagra
buy viagra cialis levitra online prescription
order viagra overnight shipping
cheapest generic viagra
buy cialis now
buy get online prescription viagra
buy viagra online alternative viagra
cheap pharmacy viagra cialis levitra
cheapest uk supplier viagra
buy viagra in the philippines
cheap kamagra uk viagra
buy free online sale viagra viagra
cialis online
order viagra on line
cheap generic viagra no prescription
cheap viagra in uk
order cheap viagra
Buy viagra Tulsa
purchase cialis online
buy viagra cheapest
buy viagra online australia
buy viagra on the internet
Buy viagra Minneapolis
buy cheap viagra viagra
buy cheapest online place viagra
order viagra air travel php
buy cheap online viagra
discount viagra europe
order viagra now
cheapest viagra world
discount viagra 10 pack generic
viagra and cialas
viagra and depression
buy cheap free online viagra viagra
order viagra usa
cheapest viagra on line
buy female viagra
buy online online viagra viagra
discount viagra perscription drug
order viagra here
buy cheap deal pill viagra
buy taladafil viagra
discount viagra sales
buy cheap viagra online now
order viagra online
buy viagra online in uk
buy kamagra viagra
buy cialis online
order viagra onlines
cheapest line viagra
cheap kamagra viagra
order viagra cialis levitra pharmacy
buy viagra 100mg
buy viagra prescription
buy viagra online online pharmacy
buy viagra per pill
buy real viagra online pharmacy
buy viagra in bangkok
cheapest viagra in uk
viagra buying
cheap viagra uk
discount viagra pharmacy online
buy lipitor
buy real viagra
buy crestor
buy cheap viagra 32
discount viagra drug
buy cheap viagra online now uk
buy discount cialis
buy line viagra
buy viagra online 35008 buy
buy viagra at safeway
buy viagra without prescription online pharmacy
buy online purchase viagra
order viagra canada
buy cheap discount levitra
cheap deal pill pill viagra
Buy viagra Pittsburgh
viagra and hair loss
buy prescription vaniqa viagra
viagra buy do nu
discount viagra prescription drug
cheap man viagra
discount viagra online
cheap viagra online order viagra now
cheapest viagra anywhere
buy viagra online at cheap price
buy herbal viagra
buy viagra where
buy viagra softtabs
viagra buy viagra online
cheap generic viagra substitutes
order viagra prescription
buy viagra and cilas
buy in uk viagra
cheap pfizer viagra
buy in online usa viagra
viagra buy generic
buy evista
buy claritin
buy sildenafil viagra
buy buy online viagra viagra
buy citrate generic sildenafil viagra
buy cipro
buy cheap viagra viagra viagra
buy levitra online viagra
order viagra viagra
cheap online purchase viagra
cheap generic viagra online
buy gw porn viagra
buy real viagra pharmacy online
cheap herbal sale viagra viagra viagra
order viagra or levitra
discount viagra mastercard
buy discount viagra
buy viagra from an online pharmacy
cheap generic substitute viagra
buy viagra in new zealand
cheap canadian viagra
buy cheap sale viagra
buy viagra generic
buy viagra in london
viagra buy
cheap viagra cialis
cheap online sales viagra
buy viagra online no prescription
cialis 32
order site viagra
buy cheap online prescription viagra
Buy viagra Long Beach
order viagra visit your doctor online
cheapest generic viagra and canada
buy viagra and cilas usa
Buy viagra Nashville
cheap soft tab viagra
Buy viagra San Antonio
buy prescription viagra
buy viagra sale
viagra and hearing loss
buy cheap viagra prescription online
order levitra
cheapest viagra generic substitute
viagra by mail canada
cheapest prices on generic viagra
buy viagra in great britain
buy viagra search find free
buy viagra cheap india pharmacy
order viagra licensed pharmacies online
viagra buy ionline
Buy viagra New Orleans
order viagra online consumer rx
cheep viagra from india
buy cheap viagra
buy deal deal price viagra
buy viagra online in the uk
over the counter drug to viagra
buy viagra without prescription
check generic order pay viagra
buy celebrex
cheap deal discount viagra viagra
cheap molde ticket viagra
cheap viagra in the uk
viagra by mail
buy viagra bradenton
seroquel
buy viagra low cost
cheapest viagra in uk cheap
discount viagra viagra
buy internet viagra
buy viagra by pill
Buy viagra Washington
buy viagra with paypal
viagra buy uk
buy viagra uk
Buy viagra Phoenix
buy discount viagra online
cheapest place to buy viagra
order forms for buying viagra
buy online drug viagra pharmacy
cheapest viagra online pharmacy
buy generic viagra usa
purchase levitra
buy online uk viagra
cheap discount lexapro online
cheap meltabs viagra
cheapest prescription viagra
buy viagra online canada
buy viagra pills
cheap drug online prescription viagra
cheap sale viagra
buy locally viagra
buy viagra in uk
cheap levitra online
cheap deal discount price viagra
buy cheap viagra online
buy online sale viagra
viagra buy viagra
buy levitra viagra
buy diflucan
buy viagra online
buy viagra in reliable online drugstore
order mexican viagra
buy viagra from brazil
viagra and cialis side effects
buy viagra onlines
Buy viagra Tacoma
viagra buy now pay later
discount viagra generic
cheapest viagra price
buy viagra buy cheap viagra index
buy cheap viagra online uk
buy cheap viagra online u
cheapest viagra and regalis
cheap viagra online uk
buy carisoprodol no prescription
viagra and cialis
buy diovan
discount levitra
levitra online
buy free viagra on internet
viagra canada price
discount viagra pills
order viagra international ships
cheapest generic silagra viagra
buy now cialis
order viagra online no rx prescription
buy cost low viagra
buy cheap viagra on the net
discount viagra order viagra discount viagra
buy viagra online order
cheap herbal viagra viagra viagra
order viagra softtabs
buy 100 mg viagra
cheapest viagra online
buy online viagra securely buy phentermine
cheap online pill viagra
cheap viagra canada
cheap uk viagra
buy form generic viagra
cheap websites for viagra
cheap lexapro online
Buy viagra Riverside
buy p viagra
buy cialis canada
cheapest viagra online plus zenegra
cheap generic viagra uk
buy viagra online cheap
order cialis online
buy now online viagra
buy norvasc
discount viagra offers
cheap viagra generic
buy cheap viagra in uk
buy viagra on-line
buy cheap generic online viagra
order viagra air travel
cheap cheap herbal viagra viagra viagra
order discount viagra
cheapest viagra uk
buy viagra for cheap
cheapest viagra us licensed pharmacies
buy lexapro
discount viagra in the usa
buy generic viagra pharmacy online
buy viagra online and get prescription
cheapest viagra tablets
cheap cheap viagra viagra
cheap overnight viagra
buy viagra for women
order viagra on-line
cheap viagra no prescription
cheap viagra 25mg
Buy viagra Oxnard
cialis 50mg
buy viagra online 35008 buy viagra
buy viagra in amsterdam
cheap viagra from pfizer
viagra canada prescription
order 50mg viagra
buy viagra price drugs on
discount viagra canada
buy cheap generic viagra online
buy buy sale viagra viagra
buy viagra australian
cheap price viagra
buy viagra at the best price
viagra by money order
imitrex
buy free viagra viagra
buy viagra order viagra
buy levitra canada
order viagra buying viagr
buy online levitra cialis viagra
cheap prescription viagra without
buy discount viagra viagra viagra
cheapest viagra substitute sildenafil
discount viagra brand drug
cheap mexico viagra
cheap online price price viagra
cheap viagra buy pharmacy online now
viagra and cialis and
order cheap viagra fas
cheap cialis online
buy viagra cheap through online sales
buy site viagra
buy caverta
order prescription viagra without
buy online pharmacy viagra
buy online pill viagra
buy viagra online 3$ per pill
cheap deal pill viagra viagra
cheapest price for viagra and cialis
buy overseas viagra
buy cheapest online viagra
cheap viagra kamagra
order viagra now viagra money order
cheapest price on viagra
buy herbal pill viagra viagra
buy real viagra online
Buy viagra Mesa
buy discount levitra
cheap viagra without prescription
discount viagra or cialis
buy viagra 32
Buy viagra Kansas City
cheapest price for viagra
buy cheap viagra on
buy cheap discount lexapro
buy viagra 50mg
buy online viagra in the uk
viagra and diabetes
buy cheap uk viagra
cheap viagra st
buy viagra contact us page
buy isoptin
cheaper cialis levitra viagra
cheap pharmaceutical viagra
over the counter drugs like viagra
buy online price viagra
discount viagra sale online
cheapest viagra overnight
buy now levitra
buy herbal viagra longer erections
cheap discount viagra
buy viagra cheap fed ex
cialis 1
buy buy cheap viagra
cheap online generic viagra
cheap viagra online pharmacy online
Buy viagra Memphis
buy cozaar
cheap viagra index
buy viagra woman
buy viagra inte
cheap drug retin viagra wellbutrin
buy viagra australia
buy online online pill viagra viagra
buy imitrex
buy nolvadex
order telephone viagra overnight delivery
order viagra
buy online viagra viagra viagra
cheap viagra ambien generic cananda
discount cialis
buy cheap site viagra
buy depakote
order viagra uk
cheap viagra direct