Compression Hosiery
For this Module
Goal
To review the supply, measuring
and fitting of compression hosiery within the NHS. Also to examine those aspects
of physiology which give rise to a need for compression hosiery and the economic
implications of patient non-compliance in this area.
Objectives
After studying this module, the
pharmacist will be able to:
- Understand the long term prognosis
of ill-fitting compression hosiery, or hosiery that is so uncomfortable or
unattractive that patients are unwilling to wear it;
- Discuss patients' perceptions of
compression hosiery
- Explain the financial aspects of
compression hosiery in the NHS
- Overcome the limitations of the
Drug Tariff and inadequacies of the present prescribing arrangements
- State what remedial action can be
taken immediately to remedy problems associated with the Drug Tariff
- Undertake a more proactive role in
the supply of compression hosiery
Compression Hosiery
Compression hosiery
is a much neglected area, and might well be described as the Cinderella of
community pharmacy services. Its poor image dates from the very thick and
unglamorous old fashioned stockings available before 1988. However, the past 10
years have seen considerable change. My own interest began some years ago when,
while looking through a cupboard belonging to a close relative, I discovered a
cache of several packets of elastic stockings, all unworn.
This raised important questions:
How often is this situation repeated in homes throughout the country? How many
pairs of stockings paid for using NHS money are sitting unused in patients'
wardrobes? How many patients are going untreated, and at what cost to the
taxpayer of the subsequent treatment required? A few years ago, the blame would
have been placed fairly and squarely at the door of the non-compliant patient.
Now the story is different, and at least part of the blame would be shifted to
the healthcare professionals for failing to recognise that the co-operation of
the patient is a prerequisite of treatment. In other words, concordance not
compliance is the key.
There is a belief among patients
that "elastic stockings" are for varicose veins, and that is true, but it is not
even half the story. There is also a belief, even among some medical,
pharmaceutical and nursing personnel, that elastic stockings are "all the same".
This is certainly not true.
Compression hosiery is a general
term embracing many different types of garment and it is necessary to make a
clear distinction between the graduated compression hosiery, which is included
in the Drug Tariff1, and the remainder. It is a common misuse of the terminology
to refer to all elastic hosiery as TED. TED is the Kendall brand name for its
anti-embolism stockings and stands for Thrombo Embolism Deterrent. Anti-embolism
stockings are not in the Drug Tariff, but they are sometimes seen in the
community. They are usually white and an enquiry to the patient will often
elicit the explanation that they were supplied by the hospital to be worn for
six weeks post-operatively, but as "they are more comfortable than the others"
they are worn in preference to the graduated compression hosiery subsequently
prescribed. Such substitutions should be discouraged because anti-embolism
stockings do not provide graduated compression.
Pharmacists may be interested to
note that the Hosiery & Allied Trades Research Association (HATRA) scale used in
Britain to measure the pressure exerted by stockings differs from the Hohenstein
scale used in the rest of Europe. As such, a compression rating of 20mm on the
Hohenstein scale will not be equivalent to a 20mm compression rating on the
HATRA scale. The differences arise partly from the method used to knit the
garment and partly from the method used to measure the pressure. It is likely
that Britain will soon have to conform to European standards in this area, as in
so many others.
Physiology and
function
In the body, the purpose of the
veins is to return de-oxygenated blood to the heart. Within the legs there is a
distinction made between deep veins and superficial veins. The deep veins lie
beneath the deep fascia of the leg, usually covered by the lower limb muscles.
Much larger in diameter than the superficial veins, their main function is to
return blood from the limbs to the heart. The superficial veins are situated in
the subcutaneous fat and their function is thermo-regulatory. Since evolutionary
man began to walk upright, a heavy burden has been placed on the circulation in
the lower limbs, where the pressure of blood entering the veins, opposed by
gravity, is very low and has insufficient energy to return to the heart on its
own.
Pressure of the venous return is
assisted by the venous pump system, which comprises a series of pumps in the
foot, calf and thigh. The deep veins of the lower limb are surrounded by
skeletalmuscle; when the muscles contract the veins are compressed and blood is
expelled from them (Fig 1). Thus regular contraction during walking pumps blood
back to the heart: with the muscles in a relaxed state, no pumping occurs (Fig
2). All veins in the legs contain flap-like valves, which ensure upward flow
towards the heart (Fig 3).
In some cases, with advancing
years, the venous return and venous pump can become less efficient and the
circulation of the limb(s) starts to deteriorate. This is known as venous
insufficiency and often the first visible sign is varicose veins. The first
event in the development of varicose veins is the failure of the flap valves,
often in the "link" veins between superficial and deep veins. Because of
deterioration of the valve, a small amount of reverse flow towards the distal
parts of the leg occurs. Under these circumstances, the valves are said to be
incompetent, the pressure on the capillaries causes them to distend, the blood
can then pool and the wall thickens and becomes itchy, painful and unsightly.
Thus is a varicose vein formed. Varicose veins are associated with a wide range
of symptoms including itching, pain, cramps and swelling. Approximately 70 per
cent of leg ulcers are caused by venous disease2.
Varicose veins are a common
condition of pregnancy said to be caused by hormonal changes, increased weight,
and the physical pressure of the foetus on the femoral vein.
As a consequence of the impaired
venous valves, the pump action of the skeletal muscle will be insufficient to
squeeze the blood upwards, and the venous pressure will tend to increase. This
increased venous pressure gives rise to the condition known as "chronic venous
insufficiency", recognised in the first place by skin changes.
Initially, brown patches appear
as a result of the deposition of haemosiderin (a breakdown product of
haemoglobin) in the skin. High pressure in the post capillary venules of the
skin causes red blood cells to escape into the tissues. The next stage is
scarring, in which the skin and subcutaneous tissues become scarred and
indurated. This indicates that the onset of ulceration is likely and, indeed,
severe skin damage ultimately results in ulcer formation (Figs 4, 5 & 6
overleaf). It is clear, then, that the blood can be pushed upwards towards the
heart by applying to the limb external pressure, greatest at the ankle,
gradually decreasing towards the thigh. This is exactly what graduated
compression hosiery is designed to do (Fig 7 ): it opposes the increased venous
pressure and improves venous insufficiency and all the associated problems. The
amount of pressure required depends upon the severity of the condition3.
Graduated compression hosiery is
also used in the treatment of varicose ulcers. Although studies have identified
that the severity of underlying venous disease is related to intractable
ulceration, very little is known about the associated risk factors4.
There is, however, thought to be a genetic component.
Treatment failure is one of the
reasons for such deterioration. First, the patient or doctor may fail to
recognise that there is a problem; secondly, inappropriate prescribing or supply
may be the cause; the patient may use the stockings incorrectly or not wear them
at all; and finally, ineffective and ill fitting hosiery may be uncomfortable
and can be damaging to the patient's legs.
On the other hand, patients who
wear their stockings can expect to see an improvement in their condition; they
should feel less discomfort, and so be able to work better, and take more
exercise. Thus patients can help their own long term prospects and avoid
becoming a future problem for their carers and the NHS. It must be emphasised,
however, that this happy prospect depends on getting the right stockings which
the patient will want to wear. It is possible.
Economics
Chronic venous insufficiency,
then, is an important problem, being the cause of 70 per cent of leg ulcers;
however recurrent leg ulcers are a significant problem, with 69 per cent of
newly healed ulcers recurring within a year5. It has also been shown
that about two thirds of patients who have been diagnosed and treated,
experience two or more episodes of ulceration, with 21 per cent of patients
experiencing more than six episodes6. Clearly, the economic
implications of this are considerable. Statistics from the Scottish Pharmacy
Practice Division show that in Dumfries and Galloway there were 1715
prescriptions for compression hosiery at a cost of £17,975.85 during the period
from December, 1995 to November, 1996. It is interesting to speculate how many
of the stockings remain unworn, and how much of this taxpayers' money will have
been wasted.
However the cost to the UK in
unworn stockings pales into insignificance compared with the cost of untreated
venous insufficiency resulting in varicose ulcers. This amounts to many millions
of pounds a year. Four layer bandaging is currently considered the most
effective treatment for leg ulcers, but it is extremely time-consuming in terms
of community nursing and thus a serious burden of cost to the NHS. Furthermore,
the bandages are not included in the Drug Tariff.
In one study, research by
McCollom, Freak et al7 indicated that over £236m was spent each year
on largely ineffective leg ulcer care. Other estimates have put the figure as
high as £400m and have also suggested that this mainly ineffective treatment
might account for 60 per cent of all community nursing time8.
There is clearly a problem with
non-compliance in the early stages of venous disease. Equally clearly, there is
a huge potential for patient benefits, savings to the NHS, and reduction of
workload. Improved compliance might actually result in a twofold financial
advantage. First, there would be less wastage from unworn appliances and
secondly there would be fewer crises requiring more expensive hospital and/or
specialist nursing care.
Compression Hosiery
The Drug Tariff
and how it works
The information in the Drug
Tariff is scattered and not always clear, so it is best used in conjunction with
The NPA Guide to the Drug Tariff and NHS Dispensing.
The Drug Tariff gives information
on compression hosiery in several sections:
- Section 1.18 iii, fee for measuring
and fitting
- Section 1.19 3a, dispensing fee
- Section 4: principal section
listing what is available, the conditions and what the Drug Tariff will pay.
- Section 11.85. This is
specification 40 for manufacturers and includes the amount of stretch
required, durability under repeated washings, and washing instructions to be
shown on the pack.
All hosiery supplied on NHS
prescription must comply with Drug Tariff specification 40, which is based on
BS6612:1985. However, not all garments corresponding to the British Standard
also comply with DT Specification 40.
Drug Tariff requirements are
performance based. The Tariff allows for several fibres or mixtures of fibres to
be used and any method of manufacture, as long as the garment produced conforms
to DT Specification 40. It follows then, that stockings produced by different
manufacturers to the same DT specifications can perform differently. So if a
patient fails to get along with one brand it is worth trying another ... and
another! Cotton mixtures are available for those who cannot tolerate synthetics
and variations such as net and flatbed are included. The NPA Guide is very
helpful here.
Products to be supplied in
accordance with the Drug Tariff have to meet certain specified criteria. The NHS
Executive at the Scottish Office states: "... applications to add products to
the GP prescribable list are measured against a range of criteria including
safety, quality and cost effectiveness. Individual manufacturers decide whether
or not to have their products included. The Department of Health acts on behalf
of all UK Health Departments in carrying out the technical evaluation procedure
... 9"
The interpretation of this,
according to the NPA Guide, is that any hosiery manufactured to the Drug Tariff
Specification, and available at Tariff price can be supplied on a GP
prescription.
There is a reasonable choice of
colour and texture in graduated compression hosiery in the UK, from five
suppliers and three manufacturers.
The Drug Tariff lists the
garments which may be supplied on NHS. There are three classes of graduated
compression hosiery offering different degrees of support for different
indications (see Table 1).
Table 1 |
Compression Class |
Conditioned Treated |
Class 1 |
Aching legs, minor varicose
veins |
Class 11 |
Moderate varicose veins,
mild chronic venous insufficiency |
Class 111 |
Chronic venous
insufficiency Venous ulceration |
Class III is indicated in the
treatment and prevention of ulcers and so is not seen so frequently in the
community as the other two. Section 4 of the Tariff states: "Any thigh length
garment for men may be supplied with suspenders, which are also available
separately. Suspender belts are also available". (It is not clear whether women
may be prescribed the suspender belts, and in practice, stockings which come
packed for men often contain suspenders.) Under General Notes for Prescribing,
the Drug Tariff requires that, before a prescription can be dispensed the
following details must be given by the prescriber:
- Quantity. Single or pair
- Article ie, B/K T/L, including any
accessories
- Compression Class I, II, or III
The prescription requirements
above are still frequently not given, and prescriptions arriving at the pharmacy
are usually incomplete. In the section 'Specially Made Garments', the Drug
Tariff states that "in cases where stock sizes are not suitable for patients,
owing to irregular limb dimensions, surgical stockings in the prescribed
compression class, to be made to the patient's individual measurements should be
specified". The Tariff does not state who should specify that a garment should
be made to measure.
Nor does the Tariff make the
sizing of the garment the responsibility of anybody in particular, but it is
usually the pharmacist's by default. Prescriptions frequently arrive at the
pharmacy without a size and often without the patient as well! The pharmacist
does his or her best, but the reality is that a patient with irregular limb
dimensions who may be in need of made-to-measure hosiery often does not receive
it because the pharmacist is not alerted. This is a matter of very great
concern, since ill-fitting garments are the most common reason for
non-compliance. Diane Kemp, district nurse and community practice teacher North
Derbyshire Community Health Services Trust is on record as saying: "Compression
hosiery is often prescribed after 'eyeing up' the patient's leg, estimating a
size and then choosing from a familiar brand stocked by the suppliers."10
It is usually recommended that
three measurements are taken, just above the ankle bone, the thickest part of
the calf, and the thigh, but it cannot be assumed that choosing a stocking with
corresponding measurements will assure a good fit and a comfortable compliant
patient.
As well as the cost price of the
garment, the Drug Tariff allows a dispensing fee of 15p plus "an additional
on-cost allowance of 15 per cent is payable when the measuring and fitting of
trusses or elastic hosiery has been carried out by the chemist and the
prescription has been endorsed 'measured and fitted.'"
Nobody, it seems, has considered
the appropriateness of this statement, but within the profession the problems of
measuring and fitting in the pharmacy are well known.
For example:
- Few pharmacies have a private room
suitable for measuring patients.
Even with private facilities a pharmacy is still a 'shop' setting and many
patients are not relaxed and come unprepared to have their measurements taken.
Because they are not sufficiently well informed, patients are reluctant to
have their measurements taken, since they believe that all stockings should be
obtainable off the shelf according to foot size. They may become impatient
with the pharmacist when told otherwise.
In addition, some patients wear so many clothes that it would be undignified
and inappropriate for them to disrobe to have measurements taken.
- Training for pharmacists to do this
job is at worst, non existent, and at best, inadequate.
- Often the prescription is brought
into the pharmacy by the patient's carer, who may be asked to measure the
patient at home. This responsibility should not be imposed on the carer.
- The prescription may arrive at the
pharmacy without patient or carer, with a batch straight from the surgery,
which further compounds the problem.
- What about fitting? How many
pharmacists have ever fitted a patient successfully, or even been shown how to
do it?
- Finally, pharmacies are businesses
and their survival to dispense medicines at all, depends upon making a profit.
It is entirely reasonable, therefore, that they should give consideration to
the costs of each operation. Yet in almost every case the"measuring and
fitting" fee will be under £1.40.
Sometimes as a last resort the
patient or carer is given an order form and asked to take the measurements at
home, but this is far from satisfactory and should be discouraged.
Pharmacies do the best possible
job within the means at their disposal, but it is not surprising that few
patients receive an adequate measuring and fitting service. The patient
disappears from the pharmacy with a packet of stockings and in most cases the
pharmacist never knows whether the stockings were satisfactory. If the patient
finds the stockings are not to his/her liking he/she may simply conclude that
compression hosiery is not for him/her, sometimes with serious consequences.
Patient
perceptions
Every pharmacist is familiar with
the following scenario.
A patient hands in a prescription
for compression hosiery. When the question of measuring and size is raised she
assumes an expression of blank amazement and wants to know why she can't just be
give a pair according to foot size, the way she has always bought stockings. If
not, she will 'take the prescription down the road'. All too often, because we
work in a commercial environment and we know the reality, we do as she asks.
Tights are another vexed
question. While it is understandable that the NHS is reluctant to supply them
free of charge, as this could be open to abuse, patients can become very angry
when they learn that tights cannot be supplied.
It is often pregnant women who
refuse everything if tights are not allowed. This is especially worrying because
patients who cannot get along with the stockings believe they must "take it or
leave it", and do not return to the pharmacy. Instead they buy "support tights"
from stocking departments in the High Street. These tights do not offer
graduated compression. Sometimes the patients are aware of this, but they prefer
to use them just the same, on grounds of cost, comfort and appearance. It is
certain that if Class I and Class II tights were included in the Tariff the
compliance rate would improve, even though some people find the hygiene aspects
of tights unattractive. Tights are also more difficult to put on than stockings
of the same class.
Talking to patients reveals much
about their lack of understanding regarding the reasons why they have been
prescribed compression hosiery . Some typical comments are:
- the doctor said 'try them'
- they're for when my legs ache
- they're for my veins
- they're for the swelling
Hardly any patients have been
recorded as remembering receiving an explanation that the condition of their
limbs is caused by underlying venous disease, which if untreated will probably
worsen, and might even become very nasty. Nobody, it seems, has suggested that
for this reason it is necessary to persevere with the stockings. There is a very
serious and important role here for the healthcare professional in educating,
informing and encouraging the patient: A little extra attention often pays
dividends.
If patients are asked how they
are getting on with their compression hosiery it quickly becomes apparent that
compliance concerns are often well founded. Some, out of a misplaced sense of
loyalty to the GP or pharmacist, will claim that they are "fine" and that they
wear them all the time, but this will not always be true! Typical comments are:
- Too long
- Too short
- Too tight
- They fall down
- Rubbed or squashed the toes, in a
closed toe type
- Band round foot too tight, in open
toe type
- Cut into the instep
- Difficult to put on
- Cut in at top (below knee and thigh
length)
- Wrinkled round the ankle
- Wrinkled behind the knee
- Patient had been told they were a
"back up". Back up to what was never revealed!
- Patient thought 'it was a course'.
No more information was forthcoming.
- Patient only ever wore tights
- Patient used them three days a week
to allow for washing and drying
Two patients had cut off the
feet, another did not like the texture of the graduated compression stockings
and so bought the anti-embolism stockings and dyed them brown 'in warm water'.
Another frail lady with match-thin legs insisted on buying Class III large and
no amount of tactful counselling could persuade her otherwise!
Patients are clearly encountering
a wide range of problems with compression hosiery, with some combining several
reasons for allowing the hosiery to remain unworn.
It is disturbing to find patients
who are wearing the stockings sometimes complain of localised tightness around
the knee or ankle. This can have a tourniquet effect, which compromises the
graduated compression intended to push the blood upwards. It is possible that
the hosiery such as this does more harm than good. This is particularly worrying
when encountered in nursing homes, where garters are used to hold up stockings.
Class II thigh length stockings
are quite difficult to put on and, curiously, a lot of frail looking elderly
ladies say that they are able to put them on unaided. Since this seems unlikely,
consideration should be given to ensuring that the stockings are not too large
and the elasticity has not gone.
Most patients seem to know that
their stockings should be washed (after each wearing), but few are aware that
each pair should be renewed every three to four months.
Suspenders,
Belts and Accessories
The only accessories permitted by
the Drug Tariff are suspenders for men and suspender belts. The NHS suspender
belt is unacceptable even for the men for whom it is intended. The suspenders
are meant to be attached to buttons inside the top of the trousers, but they
seem to be better adapted for pulling down trousers than holding up stockings.
Men themselves, however, often
prove quite resourceful. One attached the suspenders to an ordinary leather
belt, one attached the suspenders to the waist band of an artificial limb, and
one improvised by attaching the suspenders to a webbing belt which his wife had
made.
Helpful hints
Patients using compression
hosiery tend to be concentrated in the older age groups, and may suffer from
other conditions which restrict movement such as obesity, arthritis, general
stiffness or breathing problems. Any or all of these make bending to put on
elastic garments difficult, or impossible. Several appliances have been designed
in order to make the task easier. The first two are limited to patients using
open toed stockings, but the third, though out of the price range of some
patients, can prove indispensable.
- A sock made of slippery 'silk'
material is available from Medi, as the Easy On Slipper. It is placed over the
foot and the stocking can be slipped on over it. The sock is then removed by
pulling through the open toe.
- A similar, longer sock with a loop
at the toe for easier removal by attaching to a convenient hook. The device,
called the Easy-slide, is available in different sizes and supplied by
Credenhill.
- The best of these appliances is
also the most expensive. The Kendall stocking fitting frame consists of a
stout wire frame, which holds the top of the stocking open while two handles
are used to pull the stocking on.
- Leaflets are available to encourage
patients to care for their legs. An example would be 'Help and advice on leg
problems', text by Forth Valley Leg Ulcer Study Group and Health Education
Board for Scotland.
The future
As alluded to earlier, the
situation regarding compression hosiery in Great Britain is different from the
rest of Europe. For example, they have four compression classes, we have three,
the profiles are different, measurements are carried out using different test
systems and so on. Talks have been going on now for several years to try and
reach a consensus.
Next, the Drug Tariff. The range
of hosiery at present available in the Tariff is limited. This should be
extended sooner rather than later to include Class I and Class II tights,
maternity tights, thigh length stockings with an attached waist band, hold ups
(either with an adhesive rubberised band inside the top or with lacy tops).
For patient benefits and cost
saving, pharmacists must do a really good job of measuring, fitting, informing
and education, but this will never happen as long as present arrangements
prevail. Changes are necessary to allow the pharmacist to visit the patient at
home to measure, fit, explainand supply all in a single operation. This may well
prove less costly to the NHS than the usual progression towards varicose ulcers.
Recently, a portable machine,
Salzman Medico's MST MK III, which measures the pressure that a stocking is
exerting on the leg, has become available. It would prove invaluable in
domiciliary measuring and fitting. although the cost is at present prohibitive.
To quote Moffat and Dorman in the
Journal of Wound Care2 : "Patients' ability and willingness to wear
compression stockings is a key issue in successful treatment" or Chant et al who
said: "a willingness to comply with treatment proved to be a greater problem
than the ability to do so."11. Community pharmacists can play a vital role in
ensuring compliance in this poorly understood sector and the results could
ultimately be savings both in NHS resources and patient morbidity.
Solidea USA Find
Support hosiery, Maternity Maman Support Pantyhose
References
Drug Tariff refers in all case to the Scottish Drug Tariff,
December 1997. Although the Scottish Drug Tariff differs from the Drug Tariff
for England and Wales, the section on graduated compression hosiery is the
same for both.
Moffat C J, and Dorman M C, Recurrence of leg ulcers within a
community leg ulcer service. Journal of Wound Care, Vol 4n, No 2, Feb 1995
Somerville J F, Brow G O et al, The effects of elastic stockings on
superficial venous pressures in patients with venous insufficiency, British
Journal of Surgery, Vol 61 (1974) 979-981
Bruce Campbell. Thrombosis, phlebitis, varicose veins, British
Medical Journal, Vol 312, Jan 27, 1996
Monk B E, Sarkeney I, Outcome of stasis venous ulcers, Clin Exper
Dermatol, 1982: 7, 797-400
Callum MJ, Ruckley CV, Harper DR et al, Chronic ulceration of the
leg: extent of the problem & provision of care, BMJ, 1985: 290: 1855-1856
McCollum C, Freak L, Kinsells A, Walsh J, Lane C. Leg ulcer care:
an audit of cost-effectiveness. Health Trends, vol 27 no 4, 1995
Scholl Training Manual
Letter received by the author from NHS Management Executive at the
Scottish Office
Diane Kemp. Extract from a draft copy for an article 'The varicose
condition and compression stockings - the last leg'
Chant A D B, Davies L J, Pike J M, and Sparks M J, Support
stockings in practical management of varicose veins. Phlebology, 1989: 4
167-169.
Compression Hosiery,
Support hose - Legluxe.com
Assessment Questions
Compression Hosiery
Please print answer form on next page
1. All of the following are
signs of chronic venous insufficiency, except:
a. Elevated pressure in post
capillary venules
b. Skin haemosiderin deposits
c. Ankle bruising
d. Scarring of the subcutaneous tissues
2. Which statement is false?
a. Leg ulceration has a genetic
component
b. Sheer compression hosiery has been available on the NHS for 10 years
c. On-cost of 15 per cent is payable to pharmacists who carry out measuring and
fitting of compression hosiery, provided that the script is appropriately
endorsed
d. Mixed fibre hosiery cannot be prescribed on the NHS
3. Which of the following
statements is correct?
a. Anti-embolism stockings
provide graduated compression
b. Anti embolism stockings can be prescribed on the NHS
c. Class II tights are not prescribable on the NHS
d. TED is a synonym for compression hosiery
4. Which statement is true ?
a. Link veins are principally
concerned with returning blood to the heart
b. Deep, superficial and link veins are all found in the legs
c. The deep veins are thermo-regulatory
d. The superficial veins have the greatest diameter.
5. What is the venous pump ?
a. A mini-pump in the ankle
b. Flap-like valves in the veins
c. A series of pumps created by skeletal muscles contracting and forcing the
venous blood upwards
d. Residual diastolic pressure
6. Varicose veins are commonly
associated with all of the following symptoms, except:
a. Swelling
b. Itching
c. Bleeding
d. Pain
7. What is the first event in
the development of varicose veins?
a. Swollen ankles
b. Calf pain
c. Muscle cramps
d. Failure of the flap valves in the link veins
8. What proportion of leg
ulcers is caused by venous disease ?
a. 62%
b. 50%
c. 70%
d. 25%
9. The best treatment for leg
ulcers is currently considered to be:
a. Class I compression hosiery
b. Class III compression hosiery
c. An oral vasodilator
d. Four layer bandaging
10. The best definition of
graduated compression hosiery is:
a. Hosiery used for the
prevention of thromboembolism
b. Hosiery with greatest compression at the ankle decreasing towards the knee
and again towards the thigh
c. Hosiery exerting equal pressure along the length of the leg
d. Hosiery with the least pressure at the ankle increasing towards the thigh.
11. How does graduated
compression hosiery improve venous insufficiency?
a. By easing pain and swelling
b. By assisting the venous pump by forcing the blood upwards
c. By providing support during exercise
d. By preventing varicose veins from worsening
12. Considering the Drug
Tariff:
a. Manufacturers' specifications
are not included
b. Garment sizing is specified as the pharmacist's responsibility
c. Requirements are performance based
d. Dispensing fees are included in Section 1.18
13. What proportion of newly
healed ulcers recur within a year ?
a. 4%
b. 37%
c. 69%
d. 48%
14. What proportion of leg
ulcer patients experience more than six episodes?
a. 40%
b. 52%
c. 15%
d. 21%
15. What is the estimated
annual cost of ineffective leg ulcer treatment in the UK ?
a. £236m
b. £500,000
c. £10m
d. £500m
16. To be reimbursed by the
NHS, all compression hosiery must:
a. Comply with BS 6612: 1985
b. Comply with Drug Tariff Specification 40
c. Comply with DT prices
d. Comply with both DT Specification 40 and DT prices
17. The details required by
the Drug Tariff to be given by the prescriber on a prescription for compression
hosiery are:
a. Size of garment and length
b. Quantity (ie, single or pair) article b/k or t/l including accessories, and
class
c. Foot size and compression class
d. Class of garment and whether or not made-to-measure.
18. Using the Drug Tariff,
excluding made-to measure garments, what is the maximum paid by the NHS for a
prescription endorsed "measured and fitted"?
a. £1.40
b. £3.25
c. £5.50
d. £2.63
19. Using the Drug Tariff,
what is the dispensing fee for one pair of Class I compression stockings?
a. £1.50
b. 15p
c. 88p
d. £2.05
20. Choose one true statement:
a. Class III hosiery is often
prescribed for pregnant women to prevent varicose veins
b. Graduated compression is facilitated by tightness around the ankle
c. Compression hosiery should be renewed three to four times a year
d. An ankle or calf measurement plus a thigh measurement will ensure an adequate
fit for compression hosiery
