Delphi Plus: A novel methodology for identifying evidence-based data standards for health service decision-making.

The underlying tenet of evidence-based decision-making in health services is assessing all the relevant evidence. Using the traditional qualitative and quantitative approaches to identifying evidence may not capture the full spectrum of factors that need to be addressed. A selective mixed-method approach may provide a comprehensive assessment of the relevant knowledge. This paper adds to the methodological literature by outlining a novel sequential, mixed-method, exploratory process for identifying evidence-based data standards that may be used for health service decision-making. The three-phase process, entitled Delphi Plus, engages peer-nominated topic-specific experts to assess all publicly available and practice-based items and, through a series of reviews, reach an evidence-based consensus on standards for decision-making. Each process phase is outlined in-depth and supplemented by practical learnings gained through its implementation. The Delphi Plus methodology provides the first comprehensive process for combining the published and practised data to develop evidence-based data standards. The routine use of Delphi Plus would provide a framework for benchmarking in health services, enabling greater monitoring and evaluation of client outcomes and improving quality care. This manuscript describes the process of implementing Delphi Plus and provides an example of data standards generated from its use, which directly inform the Australian Government's Primary Health Care 10 Year Plan.

Implementing evidence-based clinical and business data standards in Australian private practice clinics is feasible.

AIMS: To assess the feasibility of implementing data standards in Australian primary care dietetics practices. METHODS: A mixed-methods pragmatic study of dietitians working in primary care. Using a four-point Likert scale, participants were surveyed on their baseline use of the 45 business and 33 clinical evidenced-based data standards. The content validity index and kappa statistic for each standard were calculated with a kappa statistic of 0.60-0.74 considered 'Good' and > 0.74 'Excellent'. After 4 weeks of assessment, dietitians were surveyed on the feasibility of implementing each standard and standards in total. Qualitative feedback on enablers and barriers to implementing standards was gathered and triangulated with interviews with select participants. RESULTS: Forty-five dietitians from every Australian state and territory completed both surveys (response rate: 100%). At baseline, 24% of business and 79% of clinical standards were rated 'Good' or 'Excellent' for current usage. The feasibility of implementing standards was rated 'Good' or 'Excellent for 86% of the business and 97% of the clinical standards. Software, training and time limitations are enablers and barriers to implementing standards. CONCLUSION: Embedding data standards within dietetics practices are feasible and have broad applicability for assessing outcomes of care.

Seedbed not rescue effect buffer the role of extreme precipitation on temperate forest regeneration.

Alterations in global climate via extreme precipitation will have broadscale implications on ecosystem functioning. The increased frequency of drought, coupled with heavy, episodic rainfall are likely to generate impacts on biotic and abiotic processes across aquatic and terrestrial ecosystems. Despite the demonstrated shifts in global precipitation, less is known how extreme precipitation interacts with biophysical factors to control future demographic processes, especially those sensitive to climate extremes such as organismal recruitment and survival. We utilized a field-based precipitation manipulation experiment in 0.1 ha forest canopy openings to test future climate scenarios characterized by extreme precipitation on temperate tree seedling survival. The effects of planting seedbeds (undisturbed leaf litter/organic material vs. scarified, exposed mineral soils), seedling ontogeny, species, and functional traits were examined against four statistically defined precipitation scenarios. Results indicated that seedlings grown within precipitation treatments characterized by heavy, episodic rainfall preceded by prolonged drying responded similarly to drought treatments lacking episodic inputs. Moreover, among all treatment conditions tested, scarified seedbeds most strongly affected seedling survivorship (odds ratio 6.9). Compared with any precipitation treatment, the effect size (predicted probabilities) of the seedbed was more than twice as important in controlling seedling survivorship. However, the interaction between precipitation and seedbed resulted in a 27.9% improvement in survivorship for moisture-sensitive species. Seedling sensitivity to moisture was variable among species, and most closely linked with functional traits such as seed mass. For instance, under dry moisture regimes, survivorship increased linearly with seed mass (log transformed; adjusted R2 = 0.72, p < 0.001), yet no relationship was apparent under wet moisture regimes. Although precipitation influenced survival, extreme rainfall events were not enough to offset moisture deficits nor provide a rescue effect under drought conditions. The relationships reported here highlight the importance of plant seedbeds and species (e.g., functional traits) as edaphic and biotic controls that modify the influence of extreme future precipitation on seedling survival in temperate forests. Finally, we demonstrated the biophysical factors that were most influential to early forest development and that may override the negative effects of increasingly variable precipitation. This work contributes to refinements of species distribution models and can inform reforestation strategies intended to maintain biodiversity and ecosystem function under increasing climate extremes.

Minimum reporting standards for process and outcomes assessments for private practice dietitians working in Australian primary care: The Thought Leader Consensus study.

AIM: To identify minimum reporting standards for assessing the processes and outcomes of Australian primary care dietetics practice. METHODS: A sequential, mixed-method, exploratory process with peer-nominated Australian 'thought leaders'. A literature review was undertaken to identify possible standards, followed by semi-structured qualitative interviews with thought leaders. Content analysis was used to identify a comprehensive group of items that could inform evidence-based reporting standards. Two rounds of a modified Delphi survey were conducted with the same thought leaders to seek consensus on the most relevant items. Individual items were analysed for content validity, and those with a rating of excellent item-content validity (index >0.78) were included as evidenced-based standards for primary care practice. RESULTS: Twenty-six thought leaders (response rate: 87%) from all mainland Australian states completed a qualitative interview and two rounds of modified-Delphi consensus surveys. Items were identified and categorised into three domains: business, clinical, and implementation. Content analysis identified 216 items published or used in practice by the thought leaders. After two rounds of consensus review, 97 items (45 business, 33 clinical, and 19 implementation) achieved excellent consensus ratings. Combining these items into a standardised tool, the scale-content validity index average was >0.90, which is considered excellent content validity. CONCLUSIONS: This study has identified minimum reporting standards for evidence-based process and outcome assessments in primary care dietetics practice in Australia. Incorporating such standards into a standardised tool could enable benchmarking across the dietetics workforce and contribute to a broader understanding of the dietetic impact on public health.

Perceptions of private practice dietitians regarding the collection and use of outcomes data in primary healthcare practices: A qualitative study.

BACKGROUND: Dietitians working in private practices in primary settings provide nutrition care to support individuals with the prevention and management of chronic disease. A better understanding of the type and usage of data collected by dietitians in this setting may provide insights to optimise the effectiveness and impact of the workforce. The present study explored the perceptions of leading Australian private practice dietitians on the collection and usage of data in their practice. METHODS: A qualitative descriptive study of Australian private practice dietitians, recruited by snowball sampling, was conducted on their perceptions and attitudes towards collecting and using data. Data were collected by semi-structured interviews and all interview data were thematically analysed. RESULTS: Twenty-three dietitians participated. Five themes emerged: (i) collecting data is challenging, nuanced, unclearly defined and therefore not routinely carried out; (ii) consistent data collection processes are impeded by the diversity of practise and practices; (iii) business-related data collection is essential for sustainable dietetic services; (iv) clinical outcomes are fundamental to dietetic services; and (v) standardised, integrated systems are needed to enable routine data collection and synthesis. CONCLUSIONS: Our findings demonstrate the rudimentary role business acumen has in practice viability and provides evidence to potentially re-shape the future of dietetic education in Australia. Private practice dietitians may benefit from tools and training that enable consistent collection of data about their services. Such data could enable benchmarking across the workforce and contribute to a broader understanding of dietetic impact on public health.

Author Correction: Tree rings reveal globally coherent signature of cosmogenic radiocarbon events in 774 and 993 CE.

The original version of this Article contained an error in the Data Availability section, which incorrectly read 'All data will be freely available via https://www.ams.ethz.ch/research.html .' The correct version states ' http://www.ams.ethz.ch/research/published-data.html ' in place of ' https://www.ams.ethz.ch/research.html '. This has been corrected in both the PDF and HTML versions of the Article.

Tree rings reveal globally coherent signature of cosmogenic radiocarbon events in 774 and 993 CE.

Though tree-ring chronologies are annually resolved, their dating has never been independently validated at the global scale. Moreover, it is unknown if atmospheric radiocarbon enrichment events of cosmogenic origin leave spatiotemporally consistent fingerprints. Here we measure the 14C content in 484 individual tree rings formed in the periods 770-780 and 990-1000 CE. Distinct 14C excursions starting in the boreal summer of 774 and the boreal spring of 993 ensure the precise dating of 44 tree-ring records from five continents. We also identify a meridional decline of 11-year mean atmospheric radiocarbon concentrations across both hemispheres. Corroborated by historical eye-witness accounts of red auroras, our results suggest a global exposure to strong solar proton radiation. To improve understanding of the return frequency and intensity of past cosmic events, which is particularly important for assessing the potential threat of space weather on our society, further annually resolved 14C measurements are needed.

Modeling and characterization of seismic isolation bearings

A coordinated experimental and analytical research program sponsored by the California Department of Transportation is underway to improve knowledge about seismic isolation and supplemental damping for highway bridges. The first phhase of the study is to characterize the bidirectional response of elastomeric and sliding isolation bearings for static and dynamic excitation in a thorough static and dynamic testing program. Analytical models based on classical plasticity and smoothed plasticity (Bouc-Wen) are used for representing bearing behavior. Static biderectional load histories and eartrhquake response studies show the effect of bi-directional coupling in these models compared with independent uni-directional models.(AU)