A series of posts featuring BU’s impact case studies for REF 2021. (These are edited versions of the final submissions – the full impact case studies will be published online in 2022.)

Creating a global market for a novel medical device: how BU
research helped make it happen

Research areas: Orthopaedics, Exercise Physiology

Staff conducting research: Professor Robert Middleton, Associate Professor Tom Wainwright, Louise Burgess, Shayan Bahadori, Dr James Gavin, Tikki Immins

The geko™ neuromuscular electrical stimulator

Background: The geko™ and the technology behind it is the only product of Firstkind Ltd: a battery-powered, disposable, neuromuscular electro-stimulation device designed to increase blood flow in the veins of the legs. Firstkind Ltd approached Professors Middleton and Wainwright to design and conduct the first ever study of the device in patients following hip replacement surgery. The randomised control trial (RCT) compared the geko™ with compression stockings in order to prevent deep vein thrombosis (DVT) and oedema post-surgery. Results showed that not only was the device safe, tolerable for patients, and effective in preventing DVT, but that it significantly reduced oedema.

Before the trial, the device settings had been informed by research on healthy subjects in a seated position; Middleton and Wainwright’s research discovered that the device settings did not always work optimally for patients with oedema or neuropathy, or for patients in bed whose knee was extended. Further research confirmed this and highlighted the opportunity to optimise the device further.

BU’s research built on data from a study carried out by Firstkind, which looked at patients who had not responded well to the geko™ T1 device. BU’s TEDs2 study replicated the methodology from the earlier study, with additional blood flow measurements, and used the next generation of geko™ devices. This showed that the updated devices increased blood flow, were effective in preventing DVT, and significantly reduced oedema.

Middleton and Wainwright also conducted a pilot RCT on patients with ankle sprains, which showed that the device reduced swelling. It was the first clinical trial undertaken at home, with patients applying it themselves and wearing it for at least eight hours a day for seven days, and patients showed no adverse effects.

The impact:

Benefits for patients

Before BU’s involvement, the device was designed for use in athletes and healthy individuals to aid their recovery from sport, or to prevent DVTs while flying. Wainwright and Middleton’s research led to the device being used to help patients in a wide variety of clinical settings: e.g 28 NHS Trusts are working to adopt the device for acute stroke patients at high risk of blood clots, and more than 4,700 devices have been ordered by the NHS to prevent DVTs as a potential side effect of Covid-19.

In addition, a study of post-stroke patients showed that 2.4% of those treated with Intermittent Pneumatic Compression (IPC) alone suffered from DVT within 90 days, compared with 0% of those prescribed the geko™. Patients had no adverse events and reported a greater tolerance of the geko™ than IPC.

In Canada, the device has been rolled out for chronic wound patients, leading to some experiencing complete healing, where other treatments were unsuccessful.

Approvals in the UK and USA

• BU’s research demonstrating the effectiveness of the geko™ device led to Firstkind Ltd receiving approval from the US Food and Drug Administration to use it for venous thrombosis and oedema.
• The device has also been approved for use by the UK’s National Institute for Health and Care Excellence (NICE). In its guidance, NICE estimated the cost-saving per patient using the device to be £197 (compared with those receiving no treatment) representing a significant saving to the NHS.

Firstkind Ltd acknowledged that BU’s research was pivotal in achieving both FDA and NICE approvals. Consequently, employing a specialist in medical device registration is essential to avoid any potential pitfalls that may arise during the process. https://andamanmed.com/regulatory-services/medical-device-registration/philippines/ offers expert services to help you navigate the complex regulatory landscape and ensure that your product meets all necessary requirements.

Benefits for Firstkind Ltd

The NHS and FDA approvals have expanded potential markets for the device on every continent. Firstkind Ltd. references BU’s research extensively in its brochures, demonstrating its importance in its day-to-day marketing, driving sales and commercial expansion into new markets. More than 700,000 individual units have been sold to date in at least 14 countries, and, in 2020, Firstkind Ltd. won the International Life Sciences award for the Most Innovative MedTech Company.

Delivering analytical capacity and advice to inform government of the effects of Brexit and future trade arrangements on UK food prices

Research area: Economics

Staff conducting research: Professor Tim Lloyd

Background: In 2017, Professor Lloyd was commissioned, with Exeter University colleagues, to undertake a confidential UK food pricing project for the Department for Environment Food and Rural Affairs (Defra) to assess the impact of Brexit on food prices in Britain. The econometric models at the core of the project drew on expertise developed by Professor Lloyd over two decades of collaboration with Exeter’s Professor Steve McCorriston. They found that domestic food price inflation is significantly affected by world food commodity prices, the exchange rate and oil prices, rather than domestic demand pressures and food chain costs, and that food inflation in the EU may be influenced by differences in the food sector across the Union, particularly barriers to competition. The quality and impact of the research led to Professor Lloyd being called as an expert witness as part of a House of Lords EU Committee enquiry into food price spikes.

Underlying the econometric modelling of food inflation is price transmission – the mechanism describing how price changes move through a supply chain.  Much of Professor Lloyd’s research career has been devoted to understanding the theory, methods and data that economists rely on to analyse the price transmission mechanism. In his 2016 Presidential Address to the Agricultural Economics Society, he set out this literature and his contribution to it, including the econometric methodology he helped pioneer to quantify the speed, magnitude and asymmetry of price transmission in agricultural and food markets, much of which emphasised the importance of imperfect competition (e.g. dominant retailers) in modern food chains. Professor Lloyd’s food industry expertise led to his appointment to Defra’s panel of expert advisors in 2012 and reappointment in 2018 as Brexit withdrawal negotiations intensified.

Food prices and Brexit

After the 2016 referendum, Defra commissioned the confidential development of a new food inflation model to assess the dynamic impact of the potential trade scenarios arising from Brexit. This included the impact of food prices on consumers at different levels of income, i.e. disadvantaged groups, and a detailed examination of trade in processed food and agricultural commodities.

For the first time, the project provided data that was able to provide a more accurate representation of the types and sources of UK food imports. Using these new data, Professor Lloyd led the development of econometric models that quantified the impact of agricultural and food import prices on the price of food in the UK high street, as well as other factors such as domestic agricultural product prices, manufacturing costs and most importantly, exchange rates. The work demonstrated that the geography and type of food imported into Britain impacted retail food inflation markedly, implying that the changes in trade and trade policy arising from Brexit could impact food prices significantly

The impact:

Informing Brexit negotiations: a new scenario modelling tool

The researchers used results from their econometric modelling to develop the bespoke software interface STEFI (Scenario Tool Exeter Food Inflation). With a simple, user-friendly interface, STEFI enabled non-specialists in Defra to calculate the dynamic effects of various trade scenarios. The user manual featured a step-by-step guide to inputting alternative policy scenarios and interpreting the results, filling an important analytical gap in government at the time.

Four innovative features allowed Defra to assess the food price impacts of Brexit in ways that were previously impossible, by incorporating: (i) the origin of trade; (ii) trade in both raw agricultural materials and processed food products (iii) macroeconomic factors that determine retail food prices including effective exchange rates and unemployment and (iv) manufacturing costs in the food chain.

STEFI has been used since 2019 as part of the government’s assessment of Brexit – most notably in October 2019 when a ‘no deal’ exit became a realistic prospect, and again in January 2020, to simulate the Prime Minister’s Brexit plan. The potential impact of both these scenarios on food prices helped inform the government’s position in trade negotiations. The outputs from the Brexit pricing project continue to be used by Defra in trade negotiations and policy making.

Minimising the impact on low-income consumers

Defra asked for an econometric analysis to be undertaken to assess the effect of rising food prices on consumers across the income distribution. Numerical results quantified the effects, particularly for low-income consumers, who stand to lose the most from Brexit-related price shocks. These concerns were heightened by the potentially acute impact of Covid-19 on the availability and price of food. Amid concerns over panic buying in the early stages of the pandemic, Defra repurposed STEFI to provide objective evidence to support and inform the government’s response.

Enhancing Defra’s capacity: cutting-edge research

Defra acknowledged the impact of the research by Professors Lloyd and McCorriston, stating it was ‘impossible to overemphasise the enormous contribution’ their development of STEFI had made to its capacity, and that it was ‘unparalleled in understanding food prices’. The tool remains in regular use and Defra stated it will be used to analyse other domestic and global issues in the future, such as future bilateral trade negotiations and the coronavirus pandemic.

A series of posts featuring BU’s impact case studies for REF 2021. (These are edited versions of the final submissions – the full impact case studies will be published online in 2022.)

Using a computer model (MORPH) for environmental decision-making to balance the needs of birds and society

Research area: Conservation Ecology

Staff conducting research: Professor Richard Stillman

Background: The development of BU’s unique computer modelling software, known as MORPH, addressed the need for a robust method of predicting the effects of a diverse range of activities (e.g. housing and port development, shellfishing, recreational pastimes) on legally protected bird species. MORPH creates virtual versions of real ecosystems, including realistic ways in which animals respond to changes in their environment.

BU’s research on diverse bird species globally, conducted with former colleagues at the Centre for Ecology and Hydrology (Furzebrook/Winfrith), provided the basis for MORPH’s detailed understanding of the behaviour and ecology of coastal and wetland birds. Although it is a single piece of software, MORPH can simulate multiple systems, and, in effect, learns how to mimic different environmental conditions, species behaviour and physiology. This flexibility is key, as it means MORPH can be applied rapidly to a diverse range of systems without any time-consuming changes to its underlying computer code.

It is initially set up for present-day conditions for which the behaviour of birds in the real system is known. Its predictions are then compared to observations to determine whether it represents the system with sufficient accuracy to reliably inform decision-making. The environment within MORPH is then changed to predict how changes in the real world may impact the birds, with the results used to inform decision making. MORPH is a rare example of a model that is able to make such predictions accurately, relying on the fundamental evolutionary principle that both model and real birds will always behave in ways that maximise their chances of surviving and reproducing.

Since 2007, MORPH has been used to model 25 bird species in 22 sites in Australia, USA, Europe and the UK – BU’s Individual Ecology website details all applications of MORPH, funders, publications, species modelled, issues addressed and conservation recommendations. The model is increasingly being used by industry, conservation NGOs and government organisations to improve the cost effectiveness of their work, set sustainable fishing quotas, and understand the impacts of new developments and human activity on the birds.

The impact:

Improving regulation of infrastructure development and plans

• Independent coastal partnership Solent Forum commissioned BU to measure the potential effects of housing development on the local wintering bird population. MORPH predicted that the construction of 60,000 houses over the next 13 years could potentially increase the mortality of wading birds; as a result, the developers had to offset any negative effects by making contributions to fund conservation per house built, based on a sliding scale according to the number of bedrooms. Between 2014 and 2020, this totalled £3.4 million, which went towards creating Bird Aware Solent, a partnership that aims to raise awareness of protected birds.
• BU worked with Natural England (NE) to asses the effects of habitat loss and disturbance on wildfowl populations due to new developments. This enabled NE for the first time to predict whether such losses might result in a decline in protected bird populations.
• US-based conservation organisation Ducks Unlimited commissioned BU to look at the effects of habitat loss and disturbance on black brant geese in California and used the findings as a key piece of evidence for an impact assessment of the environmental effects of the expansion of aquaculture activity in the area.

Enhancing sustainable shellfishery management to allow economic growth while better conserving protected bird species

• MORPH was used in the Wadden Sea, Netherlands – the world’s largest unbroken system of intertidal sand and mud flats – to help determine whether cockle harvesting could continue in 2020/2021. The decision depended on evidence that the management of the cockle fishery in previous years had been enough to sustain the oystercatcher population – which MORPH was able to confirm.
• The Marine Stewardship Council has used BU’s research in the management of Welsh cockle fisheries and the Exe Estuary mussel fishery to identify the amount of shellfish needed to sustain birds such as the oystercatcher over winter. This then informs the quota for fishing.

Improving evidence-informed efficiency, resource management and cost-effectiveness of conservation organisations

• BU has equipped Natural England with models and knowledge to predict in-house the effect of land use change on bird populations, enabling them to conduct a more cost-effective assessment of impacts.
• UK conservation charity Wildfowl and Wetlands Trust used MORPH to diagnose the environmental causes of the population decline of the Bewick’s Swan, currently listed as ‘Endangered’ in Europe.
• The British Trust for Ornithology now routinely includes MORPH (or related approaches) as one of its methods in conservation projects.

Digitisation of tourism and hospitality marketing: towards smart ecosytems

Research area: Tourism & Hospitality

Staff conducting research: Professor Dimitrios Buhalis

Background: Professor Buhalis has spent the past 20 years researching how Information Communication Technologies (ICTs) can revolutionise marketing in tourism and hospitality. Since his arrival at BU in 2007 his key focus has been how to use digital technology to engage with the consumer; and how tourism organisations and destinations can develop their competitiveness and improve their profitability by developing smart networks. His research during this period has focused on:

• The use of the internet (Web 1.0) to enable organisations to communicate their offerings and facilitate eCommerce transactions.
• The application of social media and Web 2.0 to interact with consumers and engage with stakeholders through two-way dynamic communications. This enables the ‘co-creation’ of experiences with customers, allowing personalisation and contextualisation, and generating additional value and loyalty.
• The development of Smart Tourism ecosystems, using technology to develop agility, facilitate value co-creation and deliver services in real time. For tourism destinations and governments, this means that they can integrate their production and supply systems, enhancing their competitiveness.
• For tourism businesses, such as hotels, travel agencies and tour operators, adopting a smart ecosystem can help develop their competitiveness and profitability through interconnectivity and interoperability.

The impact:

Tourism businesses

Individual tourism practitioners and organisations have applied insights from Professor Buhalis’ research to enhance profitability and competitiveness.  His work on co-creation has informed social media strategies for hotels across the world, enhancing their online brand reputation, improving customer engagement and increasing repeat business. These brands include:

• the world’s largest franchisor of hotels, Wyndham Hotels & Resorts – which collaborated with BU on a number of initiatives;
• Aliathon Resort, Cyprus – which estimates that Professor Buhalis’ insights have extended the tourist season, increased guest loyalty and enhanced revenue by approximately €4 million per year, 2013-19;
• Aquis Hotel & Resorts – which attributes an occupancy rate 10% above, and average room rate 8% above the competition to insights gleaned from BU’s research;
• Omnibees Booking Engine – which has based its development on Professor Buhalis’ research into smart ecosystems, enabling it to achieve the best conversion rate among booking engines.

National governments

Professor Buhalis has worked with more than 100 national governments and tourism bodies to develop e-tourism strategies, strengthen the competitiveness of destinations, and increase tourism revenue. This includes: Visit Britain, the British Hospitality Association, Tourism Australia, the Ministry of Tourism in Jamaica, the African Tourism Leadership Forum, the Ministry of Tourism in Oman and the Agency for Development of Human Resources in Cyprus, a country where he has trained more than 1,000 hotel owners and managers in the creative use of social media.

International organisations

Professor Buhalis has acted as an adviser to the UN World Tourism Organisation (UNWTO) since 2006, which has helped him to put technology and digital at the top of the tourism agenda globally.  In 2018 the UNWTO’s World Tourism Day was themed around digital technologies, with the UNWTO stating that Buhalis’ research was “a major feature” in the debate around big data, artificial intelligence and digital platforms, which all form a “central part of the solution to the challenge of marrying continued growth with a more sustainable and responsible tourism sector”.

Covid-19

During the pandemic Professor Buhalis has collaborated with the UNWTO, TravelDailyNews, hotel associations and other media organisations channels to facilitate more than 150 online live sessions and discussion forums, training industry and governments around the world on how to use smart technologies to restart tourism, adopt hygiene protocols and communicate dynamically with stakeholders.