American Journal of Health-System Pharmacy

doi: 10.1093/ajhp/65.e52pmid: N/A

This meeting of the Board was held in Seattle, Washington, at the Washington State Convention and Trade Center. The following members of the Board were present: Janet A. Silvester, Chair; Kevin J. Colgan, Vice Chair; Paul W. Abramowitz; Cynthia Brennan; Teresa J. Hudson; Stanley S. Kent; Lynnae M. Mahaney; Sheila L. Mitchell; Kathryn R. Schultz; James G. Stevenson; and Henri R. Manasse, Jr., Secretary. Also present were John A. Armitstead, Board Member Elect; Janet L. Mighty, Board Member Elect; and various ASHP staff members. The following is a summary of actions taken by the Board: Reviewed reports of officers and Board members who had represented ASHP in various activities. Ratified the ballot memorandum on e-mail approval of the minutes of the April 16 18, 2008, meeting of the Board. Ratified the ballot memorandum on e-mail approval of the 2008 2009 Leadership Agenda. Ratified the ballot memorandum entitled, “Antithrombotics and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 8th Edition.” Agreed on Board of Directors positions on proposed professional policies that were amended at the first meeting of the 2008 House of Delegates Session. Agreed to recommend that the House of Delegates adopt the Resolution entitled, “Alternative Drug Coding Systems.” Reviewed plans for the IV Safety Summit: Preventing Harm and Death from Misuse of Intravenous Medications, an invitational conference that was scheduled for July 2008. Reviewed a report on plans to retain a public affairs consultant to raise the awareness of public policy makers about the qualitative distinctions among sources of drug information Reviewed a report on the results of the April 16 17, 2008, ASHP Planning Retreat. Reviewed recent activities of the executive committees of ASHP sections and forums. Reviewed items of interest from the May 8, 2008, meeting of the Joint Commission of Pharmacy Practitioners. Reviewed preliminary financial results for the fiscal year that ended May 31, 2008. Reviewed recent activities of the Council on Credentialing in Pharmacy. Reviewed recent activities of the Pharmacy Technician Certification Board. Reviewed an update on activities of the ASHP Research and Education Foundation. Recognized the service on the Board of Directors of Dr. Brennan, Ms. Ginsburg, Ms. Mahaney, and Dr. Hudson. Addressed in executive session several confidential matters including evaluation of the performance of the Executive Vice President; performance objectives for the Executive Vice President for 2009; and organizational bonus goals for 2009. The next meeting is scheduled for September 26, 2008, in Bethesda, Maryland. Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

doi: 10.1093/ajhp/65.17.1585pmid: N/A

Developing Great Research Questions In this first installment of Research Fundamentals, a researcher explains why the most important part of the process is developing a good research question. To develop a great research question, she suggests that a practitioner–researcher ask interesting questions, select the best one, and then transform it into a testable hypothesis. Neuropsychiatric Disturbance after Initiation of Varenicline in a Patient with a History of Alcohol Abuse and Major Depression Severe anxiety, nausea, vertigo, blurred vision, and dizziness developed in a 33-year-old Caucasian man after he had taken 10 doses of varenicline in accordance with the recommendations in the package insert. At the time he started varenicline therapy, the man had a history of alcohol dependency and a major depressive disorder and had been taking fluoxetine and bupropion for at least 12 months. His neuropsychiatric symptoms subsided gradually and completely disappeared three days after he stopped varenicline therapy. Factor VIIa (Recombinant) for Acute Traumatic Hemorrhage While not a first-line treatment to manage bleeding after major trauma, factor VIIa (recombinant) reduces patients’ need for red blood cell transfusions. Summary of Evidence for Use of Factor VIIa (Recombinant) for Traumatic Hemorrhage Ref. Study Design Pts With Bleeding Cessation (%) Mortality (%) 10 Case series 80 56.5 11 Retrospective 95.6 24.4 12 Retrospective 93 31.4 15 Case series 72 39 Ref. Study Design Pts With Bleeding Cessation (%) Mortality (%) 10 Case series 80 56.5 11 Retrospective 95.6 24.4 12 Retrospective 93 31.4 15 Case series 72 39 Summary of Evidence for Use of Factor VIIa (Recombinant) for Traumatic Hemorrhage Ref. Study Design Pts With Bleeding Cessation (%) Mortality (%) 10 Case series 80 56.5 11 Retrospective 95.6 24.4 12 Retrospective 93 31.4 15 Case series 72 39 Ref. Study Design Pts With Bleeding Cessation (%) Mortality (%) 10 Case series 80 56.5 11 Retrospective 95.6 24.4 12 Retrospective 93 31.4 15 Case series 72 39 Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

Lavine,, Greg

doi: 10.2146/news080070pmid: 18714094

As the personalized medicine movement continues to slowly build momentum, the field of pain management is among the latest to benefit from technology used to tailor treatments to individual patients. Personalized medicine, in the form of therapeutic drug management and pharmacogenetics, is emerging as a way for pain management specialists to improve patients’ quality of life, said Paul Jannetto, an assistant professor of pathology at the Medical College of Wisconsin in Milwaukee. Pharmacogenetics and therapeutic drug management “provide the only objective measure of pain management physicians have to treat a patient,” he said on July 30 at the American Association for Clinical Chemistry annual meeting in Washington, D.C. Jannetto, citing statistics from the Centers for Disease Control and Prevention (CDC), said 25% of Americans suffered from a daylong bout of pain during the previous month in one survey. About 10% of Americans reported having dealt with pain that lasted over a year, according to CDC statistics. Chronic pain costs the United States $79 billion a year in medical costs and lost wages, said Nancy Bratanow, medical director at Midwest Comprehensive Pain Care in Milwaukee. Traditionally, health care providers have relied on patients to report their own pain levels to guide treatment. In some cases, therapeutic drug management and pharmacogenetics can help pinpoint potential treatment problems in patients, Jannetto said. Some tests can be used to determine how much of a specific drug is present in the body at a given point. Gas chromatography–mass spectrometry tests can be used to determine whether an optimal amount of a drug is present in a patient. This can offer clues as to why a patient may report significant pain despite active treatment. Pharmacogenetics tests can take these investigations a step further, Jannetto said. Tests on cytochrome P-450 isoenzymes can help determine if a patient is a fast, slow, or normal metabolizer of drugs, he said. Emerging technology can also be used to help detect diversion of controlled substances, he said. Screening assays can detect the presence of opioids in a patient’s system. Some pain management clinics require patients to submit to random testing to make sure the drugs are being used and not diverted. “Pain management physicians are under a lot of scrutiny,” he said. “They need to make sure they are properly managing their patients.” If opioids are found in the patient, there are further assays available to learn whether a specific drug is present, Jannetto said. But he warned health care providers about basing treatment decisions solely on the results of assays, which can register false positives and false negatives. Other evidence is needed to determine if patients are complying with their treatment regimen. Bratanow said combining therapeutic drug management with pharmacogenetics creates more objective ways to help patients achieve their respective pain management goals while protecting against diversion. For most pain management in this country, patients are treated as if they are the same. Almost all patients are initiated on standard dosages, Jannetto said. “We don’t all respond to medications the same,” Jannetto said. “We can use that genetic information up front to choose the right drug at the right dose to get the desired effect and minimize any adverse drug reactions.” While treatment is available for chronic pain, the help received is often not enough relief for many patients, Bratanow said “Despite how common pain is and how much it costs us,” she said, “40% of patients feel they are inadequately treated.” From 1988 to 1994, 3.2% of American adults were taking prescribed opioids for pain, Jannetto said. From 1999 to 2004, the percentage of adults using prescription opioids had reached 4.2%. Further evidence of the increased use of opioids is showing up in other places as well. Not only are we using them more, but we’re also seeing more deaths at the medical examiner’s office” linked to opioids, Jannetto explained. Pain management experts find themselves walking a tightrope when it comes to prescribing opioids to treat pain, Bratanow said. There are concerns over the risk of addiction for patients as well as the danger of diversion of the controlled substances. It can be a challenge to determine when a patient really needs an increased dosage of opioids or when there may be other motives involved. “We have a real problem with a lack of objective measures,” she said in determining whether treatment is effective. In some cases, there is the fear that patients are just trying to scam pain management experts into prescribing unneeded painkillers. These patients may be abusing the drugs or selling them to others, she said. Websites and fellow abusers pass on tips for what to say to obtain prescriptions for specific drugs of choice, which forces pain management clinicians to be skeptical at times, she said. Surveys delving into family and personal history of substance abuse can help pain management clinicians decide when closer monitoring is necessary, she said. Jannetto noted that old tools and emerging technology can help patients improve their pain situations. “The goal of pain management is to actually return patients to a pain level that allows them to function,” he said. Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

doi: 10.1093/ajhp/65.17.1588pmid: N/A

Hypromellose, dextrose, and glutathione balanced salt ophthalmic solution (Navstel, Alcon): The two-part product is indicated for use as an intraocular irrigating solution during surgical procedures involving perfusion of the eye. Part 1 contains hypromellose, sodium chloride, potassium chloride, dibasic sodium phosphate, sodium bicarbonate, and, to adjust the solution’s pH, hydrochloric acid or sodium hydroxide in water for injection; part 2 contains calcium chloride, magnesium chloride, dextrose, and glutathione disulfide in water for injection. Valproic acid delayed-release capsules (Stavzor, Noven): The soft-gelatin product, available in three strengths, is indicated for the prophylaxis of migraine and treatment of complex partial seizures and manic episodes associated with bipolar disorder. Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

doi: 10.1093/ajhp/65.17.1590pmid: N/A

The University of Kentucky College of Pharmacy has announced the following promotions: Jimmi Hatton, Pharm.D., FCCP, FCCM, Chair, Department of Pharmacy Practice and Science; and Kelly M. Smith, Pharm.D., BCPS, FASHP, Assistant Dean for Academic Affairs. Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

Thompson, Cheryl, A.

doi: 10.2146/news080071pmid: 18714096

Hospitals may soon have a new alternative to periodic no-charge surveys by state agencies for showing compliance with the Medicare program’s conditions of participation. DNV Healthcare Inc., with headquarters in Houston, will learn by October 8 the fate of its application to accredit hospitals for participation in Medicare. Approval of the application would give three national accrediting organizations what federal regulations call “deeming authority” for hospitals: the Joint Commission; the American Osteopathic Association, which runs the Healthcare Facilities Accreditation Program; and DNV Healthcare, which offers the comparatively new National Integrated Accreditation for Healthcare Organizations program. Possible new player DNV Healthcare said its accreditation program integrates International Organization for Standardization (ISO) standard 9001 with Medicare’s hospital conditions of participation. The standard states generic requirements for how an organization implements its management system to accomplish its work and meet customers’ needs, according to ISO’s website. ISO standard 9001:2000 West Shore Medical Center in Manistee, Michigan, has been certified to the 2000 version of ISO standard 9001 since 2001, before the National Integrated Accreditation for Healthcare Organizations program came into existence. Director of Pharmacy Michael Meagher said West Shore in 2006 started using TÜV Healthcare Specialists, the predecessor of DNV Healthcare, for third-party certification to ISO standard 9001. Before his arrival about 10 years ago, Meagher said, the hospital had been accredited by the Joint Commission. West Shore, in northern Michigan, is licensed for 45 beds but typically has a census of less than 30 inpatients, he said. “It got to the point where the expense and the resources were getting to be a little too much for a smaller institution,” Meagher said of the Joint Commission’s accreditation program. “So we went without anything, essentially, except for the state inspections for a period of time.” But the hospital realized, he said, that it needed something to “tie everything together.” He said the ISO standard on quality management offered what the hospital’s executive team sought: “a framework for us to put all the pieces together.” Using that framework, the hospital incorporated the Medicare conditions of participation and various accreditation and regulatory requirements into its quality management system and created a management systems manual. The National Integrated Accreditation for Healthcare Organizations program, which became available after West Shore created its ISO-related management systems manual, spells out the Medicare conditions of participation, he said. Being that the ISO standard is not prescriptive, Meagher said, the pharmacy and other departments seek out and incorporate best practices and, as appropriate, other standards into the hospital’s management systems. The pharmacy, for example, looks at material from the Institute for Safe Medication Practices and the National Patient Safety Goals from the Joint Commission in determining standards of practice. To get the pharmacy started, Meagher, Pharmacy Clinical Coordinator Ronald Villamaria, and one of the staff pharmacists rewrote all of the department’s policies and procedures. “A big piece of ISO is document control,” Meagher said. Only the latest version of each document, such as a drip-rate or dosage chart, should be accessible. The hospital created one online repository for documents, he said. Each document bears a revision date and document control number. Personnel have been told to go online to see the official version of any current document. In addition to the external audit every three years for ISO 9001:2000 certification and annual external surveillance audits, West Shore undertakes ISO-suggested internal audits during the year, Meagher said. The hospital has 25 employees, including Meagher and Villamaria, who have been trained to conduct ISO 9001:2000 audits of departments other than their own. “What those auditors do,” Villamaria said, “is . . . evaluate the performance of each department or area within our organization and make sure that we’re trying to comply with the standards that ISO has put into place.” Mary Margaret Wilberg, West Shore’s director of performance improvement, said a discrepancy between how the management systems manual and how a frontline worker describe the same policy, process, or procedure becomes an issue in need of attention. One type of internal audit suggested by the ISO standard is the “tracer,” Meagher said. This audit follows a patient from arrival through discharge. Wilberg credited the internal audits with nearly ridding the facility of the “silos” that can keep one hospital department from working well with another. As for certification to participate in Medicare, West Shore easily passed its unannounced biennial state inspection in mid-2007, she said. Current players About 83% of the nation’s 4020 acute care hospitals choose accreditation as their means of showing compliance with Medicare’s conditions of participation, according to the Department of Health and Human Services. Data available at the American Osteopathic Association’s website indicate that the Healthcare Facilities Accreditation Program accounts for no more than 5% of these accreditations. The Joint Commission dominates as the national accrediting organization for hospitals. Despite past differences, these two accrediting organizations have standards that are now “very similar” in content with regard to hospital pharmaceutical services, said Patricia Kienle, director of accreditation and medication safety at the Cardinal Health Center for Safety and Clinical Excellence. In fact, she added, the content is almost the same as the “interpretive guidelines” from the Centers for Medicare and Medicaid Services (CMS). The guidelines, according to CMS, offer “authoritative interpretations and clarifications of statutory and regulatory requirements and are to be used to make determinations about a provider’s compliance with requirements.” Basis for deeming authority When the federal government established the Medicare and Medicaid programs in 1965, it decided that an institution “accredited as a hospital by the Joint Commission . . . shall be deemed to meet the requirements” for participating in the Medicare program. With such an accreditation, the law said, the institution does not have to seek certification by a state survey agency. The Joint Commission never had to, until recently, apply to secure deeming authority for hospitals. However, federal law has required other national accrediting organizations to apply initially and then, if approved, reapply periodically. But Congress in July revoked the Joint Commission’s so-called unique deeming authority. Legislators have given the Joint Commission up to 24 months to apply for deeming authority and receive a decision from CMS. The Joint Commission, in a statement released July 16, said the accrediting organization “will apply for and is confident that it will receive deeming authority.” Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

doi: 10.2146/cor080015pmid: N/A

Treatment of poisoning caused by β-adrenergic and calcium-channel blockers (October 1, 2006, Clinical Review). On page 1832, the last sentence of the caption for Figure 1 should indicate that the figure was adapted, with permission, from reference 13. Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

Lavine,, Greg

doi: 10.2146/news080072pmid: 18714097

Out of the 3.6 billion prescriptions annually filled in the United States, roughly 2% are for drugs that lack federal approval, according to FDA officials. “Just because a drug is on the market, just because it has become part of the pharmaceutical armamentarium, does not mean it is safe and effective,” said Deborah Autor, of FDA’s Center for Drug Evaluation and Research (CDER). Over the past two years, FDA has cracked down on eight classes of “unapproved” drugs, but more work remains for investigators, said Autor, speaking in Rockville, Maryland, at a July 17 media briefing about enforcement efforts. With the Unapproved Drugs Initiative, FDA is trying to protect consumers from drugs that entered the market decades ago, before the government required evidence of safety. FDA on July 30 announced one of its most recent enforcement actions involving guaifenesin, an expectorant found in some cold and cough medicines. Officials seized more than $24 million in drug products from KV Pharmaceuticals of St. Louis, Missouri. The company had been warned to stop production of what FDA called unapproved extended-release products containing guaifenesin. Michael Levy, of CDER’s Office of Compliance, said that guaifenesin is an approved drug but that some companies were making unapproved versions of products containing the drug. Enforcement efforts for unapproved guaifenesin-containing products date back to May 2007. FDA has taken action against the makers of the following types of drugs: carbinoxamine, quinine, ergotamine, trimethobenzamide suppositories, hydrocodone, and colchicine for injection. Though some of these drugs are present in products having FDA-approved labeling, the agency has focused on companies whose products contain unapproved drugs and lack approved labeling. Autor, director of CDER’s Office of Compliance, said that while many other unapproved drugs are still being manufactured, her office would not discuss future targets or timelines for enforcement action. Levy said future enforcement efforts generally will focus first on patient safety, followed by actions to deal with unapproved drug products that compete with drugs with FDA-approved labeling. Autor said postmarketing monitoring is among the problems FDA faces when trying to deal with unapproved drugs. With properly approved drugs, FDA has a better chance of discovering unusual rates of adverse events in a product. For example, if the labeling for an unapproved drug indicates there is a risk of death, then the manufacturer never has to report any deaths related to the product. For drugs with FDA-approved labeling, FDA must be notified when a higher-than-expected number of deaths occur in relation to the product. Another problem is that the labeling for unapproved drugs may lack all of the appropriate cautions and could contain inaccurate or dangerous dosage information. One cold remedy pulled from the market included dosage recommendations for one-month-old children. An FDA reviewer called that unapproved product—which has long since been pulled from the market—“SIDS in a bottle,” due to the risk of death for infants. In addition to enforcement actions, FDA is also trying to work with pharmaceutical manufacturers that are now making unapproved products. The federal agency has set up ways to assist companies in applying for approval to potentially bring their unapproved products into compliance. “We think it is imperative that these drugs go through the FDA approval process so we can learn once and for all whether they are in fact safe and effective,” Autor said. In some cases, these unapproved drugs are being used in place of similar products that already have FDA approval. Autor said this practice hurts companies that have already made the investments necessary to go through the approval process. “We believe that undercuts the integrity of the drug approval system,” she said, “and frankly undercuts the incentive for companies to do the right thing.” FDA has received more than 100 telephone calls and a number of drug applications from companies hoping to bring their products into compliance since the enforcement movement began in June 2006. “Overall, we have been very successful in that respect in the last two years,” Levy said of helping companies come into compliance, “although we certainly have a lot more work to be done.” Autor said not all unapproved drugs are problems. She said phenobarbital, an unapproved compound used to control seizures, can be useful for some patients. “It would be much better if someone went through FDA to get this approved for safety,” she said. Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

Traynor,, Kate

doi: 10.2146/news080073pmid: 18714098

Starting this fall, companies that develop new drugs to treat neglected tropical diseases may be eligible for a new kind of reward—a priority review voucher from FDA. Issued on approval of the neglected-disease drug, the voucher will entitle the holder to an expedited review of a different drug that would not normally qualify for such consideration. The voucher program was created by the Food and Drug Administration Amendment Acts of 2007, which names 16 tropical diseases for which manufacturers can earn a priority review voucher. “Congress is attempting to stimulate the development of new drugs for certain tropical diseases, offering additional incentives for obtaining FDA approval for new drugs to treat those diseases,” explained Theresa M. Mullin, FDA associate director for planning and business informatics. The law allows the drug maker to keep the voucher or sell it, and the Duke University economists who first proposed the system in a 2006 Health Affairs article estimated that each voucher could be worth more than $300 million. The purported value arises from using a voucher to bring a lucrative new drug to market six months after submitting an application to FDA—about a year earlier than is likely under a standard review. Mullin said FDA legal experts’ interpretation of the statute is that it supports just one transfer per voucher, not multiple sales to multiple manufacturers. She said FDA will issue guidance about the voucher program before its late September start date. But even if companies immediately embrace the program, FDA does not expect to start issuing vouchers right away. “The first thing we will see is the application for a new molecular entity for a tropical disease indication that fits the criteria laid out in the law,” Mullin said of the process. “If that application meets those criteria and is approved, then [the applicant] will receive the voucher.” Mullin said FDA does not know how popular the program will prove or how much of the agency’s staff and resources will be needed to handle the vouchers. “I think we’re sort of waiting to see how it goes,” she said. An early test of the program could come from VioQuest. The three-person, New Jersey-based company owns the U.S. rights to sodium stibogluconate, a drug undergoing testing in clinical trials for the treatment of solid tumors. But sodium stibogluconate has been used for decades outside of the United States to treat leishmaniasis, a disease caused by a protozoan parasite and transmitted by sand flies. Leishmaniasis is one of the diseases for which newly approved drugs can earn a priority review voucher. The World Health Organization estimates that 12 million people worldwide are infected by Leishmania species, with 2 million new infections occurring annually. About 25% of new cases each year are the visceral form of leishmaniasis, which is deadly if untreated. Leishmaniasis is a rare disease in this country, but more than 1000 cases of cutaneous leishmaniasis—sometimes called Baghdad boil—have been reported in U.S. soldiers serving in the Persian Gulf. Americans diagnosed with cutaneous leishmaniasis can be treated with sodium stibogluconate under an investigational new drug protocol. FDA has classified sodium stibogluconate as an orphan drug for the experimental treatment of cutaneous leishmaniasis. VioQuest, through a cooperative agreement with the U.S. Army, has Phase III clinical trial data supporting the use of the drug for this indication. VioQuest President Michael D. Becker said his company plans to file an application with FDA for the treatment of cutaneous leishmaniasis. He said the application could be ready as early as the end of this year, with mid-2009 as a more conservative time frame. If all goes well, VioQuest could obtain a priority review voucher as early as next year. “We view ourselves as being somewhat in the catbird seat with regard to the vouchers, because we have a drug that is already very close to being submitted to the FDA,” Becker said. “And it’s already got orphan drug designation, so it’ll be an accelerated review as well. So six months from submission, we should be in a position to be awarded the voucher, if we’re successful.” Becker said VioQuest had no idea when it acquired the rights to sodium stibogluconate that the voucher program would exist. He said the company’s interest was and remains to develop sodium stibogluconate as a cancer treatment. “We’ve grown affectionately to refer to it as the Willy Wonka ticket,” Becker said of the voucher opportunity. “It was like opening up a candy bar and then suddenly finding this golden ticket in the wrapper.” He said VioQuest is actively seeking a partner to whom the voucher could be licensed, should it ultimately be awarded to the company. Because the cancer therapies the company is investigating would already be candidates for priority review, the company would gain more from selling the voucher than using it for a VioQuest drug, Becker noted. “Any way that we can monetize that asset today will help with oncology trials that we’re doing,” he said. Lee Vermeulen, director of the Center for Drug Policy at the University of Wisconsin School of Pharmacy in Madison, called the voucher program “a really interesting, novel idea” with the potential to drive the development of drugs for neglected diseases. Because it is funded by user fees from the pharmaceutical industry, Vermeulen said, the voucher program appears to be advancing a critical public health need in a “cost-neutral” way for the federal government and today’s taxpayers. But Vermeulen noted that the law lacks important provisions that appeared in the initial proposal for the program. These include requirements that the applicant forgo patent protection for the neglected-disease drug and make a commitment to manufacture it. “This legislation . . . is going to address the basic science, the clinical research that’s needed to prove that the drug does in fact manage this disease and is safe to use,” Vermeulen said. “We’re still going to be faced with the problem of, ‘How do we get it into the hands of the people who need it?’ This is something where broader international cooperation is going to be needed.” Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.

doi: 10.1093/ajhp/65.17.1596pmid: N/A

• Starting in 2013, Medicare prescription drug plans must cover barbiturates if used to treat epilepsy, cancer, or a chronic mental health disorder. Plans will also have to cover benzodiazepines. The Medicare Improvement for Patients and Providers Act of 2008 amended a section of the law that prevented Part D from covering prescriptions for certain medications. • Kentucky-based Omnicare Inc., which provides pharmacy services to residents in long-term-care facilities and other chronic care settings, in July acquired Advanced Care Scripts Inc., a specialty pharmaceutical services provider. Copyright © 2008, American Society of Health-System Pharmacists, Inc. All rights reserved.