Material properties and bioactivity of a resin infiltrant functionalized with polyhedral oligomeric silsesquioxanes.

OBJECTIVES: To investigate the effect of methacrylate polyhedral oligomeric silsesquioxanes (POSS-8) on various material properties and mineral precipitation potential of a resin infiltrant. METHODS: A TEGDMA-based resin infiltrant was mixed with 0.5, 1, 3, 5 or 10 wt% POSS-8 or left unchanged (control). Degree of conversion (DC), water sorption (WS), viscosity, elastic modulus (E-modulus), flexural strength (FS), Knoop microhardness (KHN) and softening ratio (SR) were assessed. Growth of calcium phosphate (Ca/P) precipitates infiltrant-treated bovine enamel and dentin specimens immersed in artificial saliva or artificial dentinal fluid, respectively, for 28 days was analyzed by scanning electron microscopy and energy-dispersive X-ray spectroscopy. For viscosity assessment, pure TEGDMA filled with 0-10 wt% POSS-8 was used. Statistical analyses were performed using ANOVA and Tukey's post-hoc tests (p < 0.05). RESULTS: POSS-8 did not change the flexural strength, water sorption and softening ratio. The apparent degree of conversion was increased at lower concentrations only while E-modulus remained constant in almost all groups. The particles led to a slight decrease of KHN at concentrations below 3%. The effect on viscosity is comparable to the reinforcement effect. Ca/P precipitates formed on dentin specimens treated with POSS-8-filled infiltrant after 4 weeks of immersion, but were not detected on the control infiltrant. The mineral precipitation on enamel was not improved by POSS-8. SIGNIFICANCE: POSS-8 particles did not worsen the material properties of the resin infiltrant, while the Ca/P precipitation on dentin was stimulated.

Telepsychiatry in the heartland: if we build it, will they come?

The quality of care provided by telemedicine and its acceptability to persons who live in rural areas is largely undetermined. In this study, service satisfaction and functional status in persons using telemedicine was compared to those receiving face-to-face services at two rural sites over a 2-year study period. Similar ratings of satisfaction and clinical status were observed in twelve patients who received services under both modalities. Although there are many obstacles to successful program implementation, telepsychiatry appears to offer an acceptable and adequate alternative mode of service delivery to persons who live in rural areas.

Self-report of improvement following hospitalization for electroconvulsive therapy: relationship to functional status and service use.

From the perspective of the consumer, improvement is important in the assessment of treatment outcome. In order to gain a better understanding of health related factors that are meaningful to service recipients, patients who had been hospitalized for electroconvulsive therapy were surveyed following discharge to the community. Self-reported improvement was related to frequency of social contact and being able to engage in useful work. It was also related to a global-assessment-of-functioning score at the time of discharge from the hospital. The receipt of aftercare was not related to the degree of self-reported improvement in this study.

The long-term effect of outpatient commitment on service use.

The long-term effect of outpatient commitment on service use was evaluated in 81 patients with serious and persistent mental illness. An increased number of outpatient visits and a decreased number of hospital admissions, total hospital days, and lengths of stay were observed during commitment periods of greater than 1 year relative to levels of use in the same patients over the 12-month period preceding commitment. This study provides support that outpatient commitment improves compliance with outpatient treatment and reduces hospital use in patients who are on outpatient commitment to a single treatment agency for periods up to 5 years.

A survey of burnout among mental health center directors in a rural state.

The executive directors of all Iowa community mental health centers were surveyed in order to determine the relationship between work environment and job burnout. Organizational characteristics related to "rurality," i.e., location in a rural county, fewer employees, smaller budgets, and more time spent in direct clinical care, were not associated with burnout among directors in this rural state. Implications of the effect of service reorganization on burnout in human service providers in regard to rural health policy, work force issues, and directions for future research are discussed.

Acceptability of telepsychiatry to a rural population.

Sixty-seven residents of a rural Midwestern state were surveyed by telephone to determine which factors influence their willingness to receive mental health services through live, two-way audio and video transmission. Two-thirds of the survey respondents were willing to participate in telepsychiatry. Many expressed reluctance, however. They were concerned about maintaining confidentiality, and they perceived telepsychiatry as impersonal. Medicare enrollees and older survey respondents were less willing than younger respondents to endorse the use of telemedicine.

Relationship between service effectiveness and satisfaction among persons receiving Medicaid mental health services.

Relationships between service satisfaction, life satisfaction, and self-reported mental health status were examined for Iowa Medicaid mental health service recipients. Of the 16,579 persons who received services in 1993, a mail-out survey was sent to 2,520 persons and returned by 815 (32.3 percent). Persons with schizophrenia reported greater service satisfaction and life satisfaction than persons with other diagnoses, and their ratings of their mental health were higher. A relationship between service satisfaction and current life satisfaction was observed for persons with schizophrenia, affective disorder and adjustment disorder, but not for persons with anxiety disorder.

Quality assessment in a Medicaid managed mental health care plan: an Iowa case study.

Clinical quality was assessed in a statewide Medicaid managed mental health care program. Because of the limited quantity and scope of the available clinical data, the quality of clinical care could not be adequately assessed. The implications of this finding for the evaluation and oversight of quality in public sector managed care plans is discussed.

Implementation of Medicaid Managed Mental Health Care in Iowa: problems and solutions.

Under the terms of a 1915(b) waiver, Iowa implemented a statewide carve-out program in 1995 for the management of mental health services for Medicaid recipients by contracting with a private for-profit corporation. In this commentary, the strategy used to develop the Medicaid managed care contract in Iowa is briefly summarized. Problems that were encountered in program implementation and regulatory attempts to address those issues are described. Suggestions for other states regarding the development, implementation, and oversight of contracts for managed care so that they might be able to deliver comprehensive mental health care services with acceptable standards of care quality are offered. By including appropriate contract specifications, providing mechanisms for oversight, and enforcing standards of care in Medicaid managed care contracts, many problems that occurred in Iowa may have been minimized or avoided. This experience can provide a valuable lesson for similar program initiatives in other states.

Capacity of rural community mental health centers to treat serious mental illness.

This study evaluates the capacity of rural community mental health center staff to treat persons with serious mental illness (SMI). A 20-item survey was mailed to 720 providers in 34 community mental health centers (CMHCs) in Iowa. Responses were received from 285/680 persons in 32/34 centers. The confidence and interest in receiving additional training in tasks necessary for the care of persons with SMI was assessed for staff members of various disciplines and both confidence and training interest was found to vary by discipline. Recommendations to enhance CMHC capacity to treat persons with SMI are discussed.

County funding of mental health services in a rural state.

Relationships between funding for mental illness in Iowa counties and county wealth, political activism, need for public services, rural culture, and policy makers' attitudes were examined. Counties with fewer people, lower proportions of persons with college education, higher proportions of rural and elderly residents, higher rates of poverty, and a higher proportion of income from farms spent less money on mental health services. Regression analysis indicated that the size of the county population and the proportion of persons receiving Medicaid funds explained 96 percent of the variation between county budgets.

A survey of county boards' views of funding for mental retardation versus funding for mental illness.

The state of Iowa mandates services for persons with mental retardation but not for those with mental illness, resulting in widely divergent spending for the two populations. Members of 98 of the 99 county boards of supervisors were interviewed to determine differences in attitudes about services and funding priorities. Respondents were more willing to provide supportive services to persons with mental retardation and acute treatment to persons with mental illness. Only 16 percent believed that persons with chronic mental illness should be a first priority for mental health funds. Respondents tended to disagree not about whether services should be funded but about who should fund them. Three-fourths believed that the state should fund such services.

The impact of case management on utilization of community support services in a rural state.

The authors report on a study testing the hypothesis that persons with serious mental illness (SMI) would report more utilization of community support services if they had a case manager. Individuals with SMI were asked to complete a survey reporting their use of 10 community support services and case management. Having a case manager was not associated with increased utilization of any support service or case management by persons with serious mental illness in this rural state.

Oversight of managed care for behavioral health services.

Contract specifications for behavioral health services can be used to ensure that services are accessible, efficient, and effective. Staff-per-population ratios and service utilization rates derived from the health services research literature, are proposed as a practical set of performance indicators. Structural, process, and outcome indicators are included. Examples include therapist full-time equivalents per 1000 cases (structural), number of crisis calls per 1000 enrollees (process), and number of emergency department visits per 1000 (outcome). The need for occasional clinical audits and further research in other areas is discussed.