Earnings Call Transcript - BSX Q4 2021

Operator, Operator

Good afternoon, ladies and gentlemen, and welcome to the Apollo Endosurgery Fourth Quarter and Full-year 2021 Results Conference Call. At this time, all participants have been placed on a listen-only mode, and we will open the floor for your questions and comments after the presentation. It is now my pleasure to turn the floor over to your host, Matt Kreps. Sir, the floor is yours.

Matt Kreps, Host

Thank you, John. And thanks everyone for participating in today's call to discuss Apollo's fourth quarter and full-year 2021 financial and operating results. Joining me on the call today are Charles McKhann, Chief Executive Officer, and Jeff Black, our Chief Financial Officer. Today's call will include slides to accompany the audio presentation. For those joining us by telephone, you can download a copy of the slides at our investor relations site, ir.apolloendo.com, and choosing Events and Presentations. Before we begin, I would like to caution listeners that comments made by management during this conference call will include forward-looking statements within the meaning of federal securities laws, including Apollo's financial outlook and Apollo's plans and timing for product development and sales. In addition, there is uncertainty about the continued spread of the COVID-19 virus and the ongoing impact it may have on our operations, the demand for our products, global supply chains, and economic activity in general. These forward-looking statements involve material risks and uncertainties, and Apollo's actual results may differ materially. For a discussion of risk factors, I encourage you to review the company's most recent annual report on Form 10-K and our most recent Form 10-Q. The content of this conference call contains time-sensitive information that is accurate only as of the date of the live broadcast, February 22, 2022. As required, except as required by law, Apollo undertakes no obligation to revise or update any statements to reflect events or circumstances after the date of this call. Additionally, today's discussion will include certain non-GAAP financial measures, which we believe provide an additional tool for evaluating the company's core performance. Management uses these metrics in its own evaluation of continuing operating performance, and as a baseline for assessing the future earnings potential of the company. Included in our press release issued today are financial results and corresponding 8-K filing, which contains supplemental tables reconciling non-GAAP figures to their closest GAAP comparable. And now I'd like to turn the call over to Charles.

Charles McKhann, CEO

Thanks, Matt. And thank you everyone, good afternoon. Thank you for joining us. Next week will mark one year since I joined Apollo Endosurgery. I am truly grateful for the honor of leading this team and this company with such unique products that impact patients' lives. Last year, I laid out a three-phase strategy as described on page 3. The first phase was to energize the business by building momentum across all three of our product lines while executing on foundational initiatives that can set us up for growth in the years ahead. The second phase is to accelerate the business by developing new indications in markets. The third phase is to lead in the fields of advanced defect closure and endoscopic treatments for weight loss. As we implement this strategy, we have bolstered the Apollo leadership team by bringing in new talent into the organization. We are focusing our efforts on developing large market opportunities. I'm pleased to report today that in the past 12 months and in Q4, we’ve made tremendous progress, which has strengthened the team at Apollo at all levels. Earlier in the year, we brought on new commercial leaders in the U.S. We brought in Jeff Black as our new CFO who's with me today. Just in January, we announced the addition of Keely Scamperle to lead our reimbursement and market access efforts. Keely is an experienced professional and is already working on building her team that will lead our reimbursement efforts in facilitating patient access for our products. We've nearly doubled our sales team in the U.S. and we've added to our OUS team. We're building our marketing and trading capabilities and becoming a more professional selling organization. We strengthened our R&D and engineering team and are implementing new processes to enhance our new product pipeline. We are addressing a historical underinvestment in other critical functions like operations, supply chain, business analytics, and customer service. Simply put, we have very talented people at Apollo and I’m very proud of the work they’ve done. We've just not had a scalable organization. So we're strengthening our capabilities across the organization to support our growth plans. We’re building and developing a new culture, focusing on a set of five core values that I’ll come back to later in the discussion. In summary, at Apollo, we're undergoing substantial change in our team, our processes, and our culture. We anticipate that these changes will allow the company that has historically struggled at times and underperformed to become a growth engine. Often when a company undergoes this much change, the business needs to take a step backwards before moving ahead with renewed confidence. I’m very pleased that that is not the case for Apollo in 2021. For the year, we delivered 50% revenue growth, and for Q4, we delivered 26% growth. Despite a meaningful impact of the omicron variant in many markets in Western Europe and the U.S., our growth has been balanced across product lines with OverStitch, ORBERA, and our newest product, X-Tack, all contributing to growth. We’ve seen balanced growth across geographies with strong performance in both the U.S. and international markets. While we kick-started the business in 2021, we’ve also created a foundation for the years ahead. In our advanced GI franchise, X-Tack is an important new product for us. We gained initial traction in the marketplace and published the first clinical data for the product. In our endoscopic weight loss franchise, obesity is a global epidemic that remains largely unchecked and the opportunity for endoscopic weight loss therapies is tremendous. 2021 was a year of important strategic milestones. Early in the year, the AGA implemented new clinical practice guidelines for the first time ever in favor of intragastric balloon therapies. The MERIT investigators presented the initial results at the IPSO meeting in the fall. We submitted a new De Novo 510(k) application for Apollo ESG and Apollo REVISE. Throughout the year, we saw an emergence of new endobariatric programs in both academic and private practice settings. In the area of NASH, we received a breakthrough designation for ORBERA for the treatment of NASH in Q1 of last year. We’ve also been collecting data on ESG and working through the best strategy to address this large market opportunity. On our balance sheet. In 2021, we secured access to $175 million in capital. We now have a strong balance sheet to support our growth initiatives. Page 5 gives you a sense of the balance I just mentioned. On the left side of the page, you can see 50% year-on-year revenue growth, 55% for the ESS franchise, and importantly, 50% for the IGB franchise. The figures relative to 2019 are shown as well. Another interesting development has been the growth in our top 10 accounts. We saw 85% year-on-year growth in our top 10 accounts, and the average sales for Apollo in those 10 accounts is more than $600,000. We believe this indicates the scale we can drive as we increase penetration of our products into our largest customers. For X-Tack, we continue to gain traction and we saw 40% sequential quarter-on-quarter growth for X-Tack. We had important milestones for both the MERIT study and the De Novo 510(k). Related to MERIT and clinical data for ESG and revisions, we expect conditional presentations of the data at the upcoming DDW meeting. For MERIT itself, the investigators are working on the publication and we look forward to that in the months ahead. Jeff will now provide a review of our financial performance, and I’ll be back to provide additional commentary on our priorities for the year ahead.

Jeff Black, CFO

Thank you, Charles, and good afternoon, everybody. Thank you all for joining us today. I'll spend a few minutes to recap our financial results and then hand it back to Charles to discuss our 2022 outlook and strategy. Starting with revenue on Slide 7. In Q4, we continued to see strong year-over-year growth across the product portfolio, and our fourth consecutive quarter of double-digit growth. That was against the backdrop of pandemic-related pressure. As we all know, this has been a changing dynamic throughout 2021, and we did see pressure on Q4 volumes. Outside the U.S., we saw pressure earlier in the quarter in concentrated markets, particularly Western Europe. Inside the U.S., we began to see slowdowns later in the quarter, predominantly in academic hospitals and larger community hospitals where access was more limited. Even with this pressure on procedure volumes, we still maintained a healthy monthly revenue cadence in December, consistent with the rest of the quarter, where we did not see the ramp that we expected in the last half of December. That was really the difference between hitting the low end of our annual revenue guidance and the high end or better. Growth in the fourth quarter was balanced between the U.S., where we saw 25% growth, and international, which grew 27%. Globally, our endoscopic suturing business was up over 37% in the fourth quarter, which highlights continued demand for our OverStitch and X-Tack products across a broad range of indications. Globally, ORBERA revenue was up 20%, which was below our blended growth rate, really due to volume pressure in the U.S., where growth was about 6%. We believe this downtick is transitory and primarily attributed to inpatient hospital settings in the U.S. For the full year, we saw revenue growth of 50% and gained balance across our U.S. and international businesses and across product lines. Overall, we're pleased with our revenue performance in 2021 and our ability to navigate a challenging fourth quarter for Medtech broadly. Turning to gross margin on Slide 8. In the fourth quarter, we saw gross margin improve by 40 basis points versus the fourth quarter of 2022, and 260 basis points on a year-to-date basis. We continue to remain focused on gross margin improvements, particularly with OverStitch, which as we've discussed, has a lower margin profile than ORBERA and X-Tack. Major drivers of overall gross margin expansion will be product mix, improved overhead absorption, and direct COGS improvement programs, again, focused primarily on OverStitch. During 2022, we should start to see the impact of some of the cost improvement initiatives that we completed in 2021. At the same time, we're navigating supply chain and manufacturing scale-up complexities, but we remain confident in our ability to drive blended gross margin to the mid-60% range over the next three to five years. Moving to Slide 9. As we look at our operating spend profile, we think it's important to exclude non-cash stock-based compensation to get a clearer picture of what our real non-core GAAP operating expense run rate is. In the near-term, we're focused on building capabilities following historical underinvestment in the business. For example, you'll see in the fourth quarter, our non-GAAP OpEx ran at about 79% of revenue, reflecting our planned investments in growth initiatives, primarily to build out our U.S. sales channel and our marketing programs as we prepare for the anticipated launch of our ESG products. In the U.S., we have a small commercial team relative to the size of our opportunities, but we made great progress throughout 2021 to expand that footprint. We started the year with 16 direct reps in the U.S. We ended with about 30 by the end of the fourth quarter. Going forward, we'll continue to evaluate the appropriate scale of our commercial team and invest as necessary. Our other focused areas of planned investment will be medical education, clinical reimbursement, product development, and continued COGS improvement initiatives. We do expect to see operating expenses increase in both absolute dollars and as a percentage of revenue, particularly in 2022, and we should start to see operating expense leverage in 2023 and beyond. Importantly, we have the ability to modulate spend as appropriate. We're now well positioned from a balance sheet perspective to make these investments. Moving to Slide 10, you’ll see that during 2021, our average quarterly burn was about $4 million per quarter. We ended the year with cash of about $92 million. Until now, Apollo has not been capitalized to adequately fund our long-term plan. The company historically did a nice job managing burn, particularly during a very challenging global pandemic. However, due to historical under-investment, the company really has not been well positioned to support even modest growth. That changed for us in the fourth quarter as we secured over $125 million in new capital and borrowing capacity, which enables us to begin making the investments required to capitalize on the opportunities we see ahead. We can do this without creating a concern about cash runway. We're now extremely well positioned to execute our growth initiatives. Turning to Slide 11. Before I turn things back over to Charles, just a few comments on our new credit facility with Innovatus Capital Partners, which we executed in December of last year. Key terms of the new term loan include a reduction in our cost of capital, an extension of our amortization by an additional 33 months over our prior term loan, and a decrease in debt service costs by nearly $30 million over the next three years. We also have additional borrowing capacity that provides flexible growth capital and strategic flexibility. At close, we drew $35 million to repay our prior debt, and we now have up to $65 million available for future tranches. $15 million will be available in 2023 and $25 million available in 2024, both based on the achievement of revenue milestones. An additional up to $25 million is available for approved strategic acquisitions as opportunities arise. Borrowings mature in December of 2027, and interest-only payments run through January of 2027. This was a great result for us. We couldn't be happier with the outcome and we look forward to our new partnership with Innovatus. And with that, I will turn the call back over to Charles.

Charles McKhann, CEO

Now as we look ahead to 2022, let me talk about our overall strategy and our outlook for the year ahead. Page 13 gives you a summary of our three product lines and the two main businesses in which we operate: advanced GI and endoscopic weight loss. We are excited that we have very attractive growth opportunities across both sides of our business. As I mentioned previously, we also are focused on pursuing large market opportunities in advanced GI, weight loss, and over time in NASH as well. For the year ahead, our outlook from a revenue standpoint is $73 million to $75 million, which translates to 16% to 19% growth compared to 2021. Let me also share a few words regarding the COVID impact. In Q4 and early Q1 of this year, we have seen an impact in markets globally. Others have reported lower procedure volumes, and issues of staffing and reduced hospital access have all presented challenges, especially in larger academic medical centers and community hospitals. That said, more recently, the omicron case counts are coming down, and the situation appears to be improving. We are optimistic that the impact of this wave is beginning to abate. As we look ahead for 2022, we see four key catalysts to drive our growth. X-Tack expansion and ORBERA resurgence, preparing for the Apollo ESG and Apollo REVISE launches, and continuing to advance our organization. The first with X-Tack, it has been a very important product for us as it adds to our portfolio in advanced GI and offers a truly differentiated product in defect closure. We’re still in the early days of the adoption of the new product and procedure, and we feel that we have much room for continued growth. Currently, more than 60% of our X-Tack sales are in upper GI. There are many reasons for this. Our OverStitch device, which is the core device for the company, is used primarily in the upper GI. Many of our existing customers perform upper GI procedures and are familiar with suturing techniques. For most of 2021, we had a small sales team in the U.S., and it’s not surprising that they had initial success with our existing customers primarily in applications in the upper GI. We continue to see positive feedback from customers about the role of X-Tack following pulp removal and lower GI cases such as the colon and duodenum. Procedure volumes suggest that these applications have the potential for much larger market opportunity. In 2022, we anticipate that we can continue to expand usage in both upper and lower GI, approach and train new users, and increase the adoption of X-Tack. Additionally, 2022 will be a year where we add clinical data for X-Tack. Today, the data is strong but limited. We anticipate additional studies on the use of X-Tack, including at the same DDW meeting that I mentioned in areas like colon procedure and stent fixation. We are ramping up our efforts in peer-to-peer education for X-Tack. The best way for physicians to learn about a new product or procedure is from their colleagues. We have conducted some peer-to-peer education to date, and we are ramping up these efforts as part of our strategy in 2022. We also have significant growth opportunity for X-Tack outside the U.S. We’ve gained initial success in several markets outside the U.S., and we are actively working towards a CE mark, which we expect in the second half of this year. Feedback from physicians, for example, in Western Europe, shows excitement about the clinical and economic value proposition for X-Tack in their practice. Turning to ORBERA, it is a meaningful part of the Apollo portfolio and offers compelling clinical benefits for patients. 2021 was a very strong year for ORBERA, accounting for more than a third of our total revenue and growing by over 50%. There are several reasons for this resurgence, many of which we view as sustainable trends. First, as it relates to COVID, we have seen a trend toward more procedures taking place in outpatient facilities and offices, which is the primary location for ORBERA. As previously mentioned, the AGA practice guidelines highlighted the clinical benefits of intragastric balloons in general, particularly the clinical benefits of a 10% total body weight loss. We've seen an uptick in physician interest and training on the balloon. We are implementing new co-marketing programs where we can work directly with practices that know how to treat patients with balloons and achieve excellent patient outcomes. We can invest in these programs, track performance, and double down on the most successful strategies. We anticipate a continued opportunity for intragastric balloons to be a significant part of a broader endoscopic weight loss practice. I will return to this here in a moment. Another catalyst is the potential for a new indication for the Apollo ESG and Apollo REVISE products. Importantly, we do not currently have an indication for these weight loss applications, and we are very careful to only promote within our approved labeling. We have submitted to the FDA and are working through that process, and we are very excited about the potential launch of Apollo ESG and Apollo REVISE. I use the word 'launch' with intention here. I want you to think about this like a new product launch, similar to pharmaceutical or large medical device manufacturers, in terms of our comprehensive strategy to maximize this opportunity. Internally, we have a significant effort ongoing in areas of marketing, medical education, training, reimbursement and market access, and sales team readiness to prepare for the launch of these new products. Our team is very busy and excited. While we prepare for these launches internally, an interesting dynamic is taking place in the medical community. The growth of new endobariatric programs in academic settings is notable. A few years ago, there were only a handful of pioneering physicians and practices in this field. The centers involved in the MERIT study were among the early adopters. Mayo Clinic, UT Houston, Brigham and Women's, Cornell, and Johns Hopkins are examples, along with leading centers internationally that have driven the development of this field. Recently, many new programs are emerging across the country in institutions such as Cleveland Clinic, UCLA, USC, West Virginia, and others. In recent months, I have personally visited many of these centers, and it's encouraging to hear about their plans to develop this emerging field of endoscopic weight loss. This is just a U.S. snapshot, and a similar phenomenon is occurring outside the U.S. in several countries as they become more familiar with the MERIT study and other data that has been collected for both primary ESG and revision procedures, as well as for the intragastric balloon and ORBERA's role in light of the new AGA practice guidelines. So this development is something we will keep an eye on. Regarding our organization, I mentioned earlier that we are retooling all those people, processes, and culture to meet our aspirations. Our new commercial leadership team is creating a professional selling organization with new sales processes. We've hired a new director of sales training and are improving our analytics and CRM capabilities. We have also recently brought on Cooley to lead the reimbursement and market access efforts. We are rallying the organization around a new culture centered on five core values: we are patient-centric, customer-focused, innovative, passionate, and we care. We care about all of our stakeholders and delivering operational excellence. We're working to build an organization that can deliver sustainable growth in the years ahead. Before moving to Q&A, I would like to take a moment to recognize Dr. Bruce Robertson from HIG Capital for his tremendous service to Apollo Endosurgery and our Board of Directors for more than 14 years. Bruce participated in the very first institutional investment round for the company in 2008 and has served on our board since then. He has been instrumental in guiding the company through its formative stages and getting us to where we are today. Bruce has also been a fantastic colleague and advisor to me in my first year as CEO. Bruce has decided to step down due to other commitments, and we wish him well. We are conducting a board search process and look forward to providing updates soon. In closing, in 2021, we made excellent progress in energizing the business and building the foundation for future growth. I anticipate that over 2022, we will begin to transition from this initial energized phase of our strategy. We have multiple catalysts for growth across our product lines and geographies, and we're putting in place the right team, processes, and culture to meet our aspirations. Thank you for your time today and for your interest in Apollo. We will now open the line for questions.

Operator, Operator

Thank you. Ladies and gentlemen, the floor is open for questions.

Eric Assaraf, Analyst

Hi, this is Eric on behalf of Josh. Thanks for taking the questions. I appreciate all the great commentary around the early experience with X-Tack. Just curious, as you get closer to European approval here, could you help us understand what would be included in your CE mark submission? Is any of your U.S. regulatory work leverageable for attaining that CE mark? Thank you.

Charles McKhann, CEO

Thanks, Eric. Yes, under the new NDR requirements, there is additional need for clinical data. We have been able to leverage some of the data from our initial clinical study that has been published, as well as much of the work that went into the U.S. application. In the past, having an FDA approval would be almost a slam dunk to follow on in the U.S. first. Right now, it’s just a timing element as our notified body works through a backlog of applications from several companies, but we believe we have the right materials they need to get the approval.

Eric Assaraf, Analyst

Understood. That's great. Thank you. Thinking about guidance for 2022, could you help us understand what COVID assumptions you're baking into the range here? Jeff, your comments around trends in December, how should we be thinking about Q1 revenues relative to the results you just delivered here in the fourth quarter? Just any commentary on the cadence of revenue through the year would be really helpful. Thank you.

Jeff Black, CFO

Sure, Eric. We haven't given quarterly guidance as you know, but it’s consistent with what you’re hearing broadly in the industry. Early in the quarter, we saw pressured volumes, much like we saw in Q4. We're starting to see some of that abate. We’re seeing nice momentum, but we can say we’re comfortable with where the street has us in terms of consensus for Q1. As we think about the acceleration of the ramp to that 20% growth, it really happens once we get beyond the COVID impact and begin to see acceleration in some of these endobariatric practices.

Matthew Blackman, Analyst

All right. Good afternoon, everybody. Thanks for taking my questions. Just got a couple. Maybe Charles, can you provide the priorities for 2022 for the U.S. commercial team? Whether it’s determining sales force size, focusing on existing accounts, or expanding the customer base, I want to understand the focus in '22. Additionally, layer on top of that the folks that you've onboarded in 2021, how they are ramping, and how productivity for the entire sales force looks like. Then just a couple of quick follow-ups.

Charles McKhann, CEO

Sure. Matt, we have our core reps, and the majority of our sales team in the U.S. carry the full bag of all three products. We’ve now layered on regional endobariatric managers focused on that area. The priorities for the first group involve continuing to identify and train new users in OverStitch and driving additional usage in our existing base. For X-Tack, the strategy remains focused on a targeted set of accounts and really driving the model of increasing adoption. It’s very important to sell the whole bag. We have some reps who sell ORBERA well and others who have less experience. Given the nice bounce for that product in the marketplace, we have a lot of learnings that will help expand it across regions that have been successful. We’re excited about the opportunities across each of those. For the newer roles I mentioned, we have a group of early adopters internally we refer to as Wave 1. We're learning from them as we have a mix of both academic and private practices and different models already having a lot of success across a range of endobariatric practices.

Matthew Blackman, Analyst

Got it. I appreciate that, and I have one more. I'm curious; you've called out the top ten accounts with something like greater than 600,000 in revenue. Are those accounts using multiple products within the Apollo portfolio? Or is it largely driven by one product? I'm trying to get at what opportunity there may be to cross-sell. As you've mentioned before, how could you turn that into a playbook for the rest of your accounts?

Charles McKhann, CEO

There’s a mix of accounts in there. Some are broad-based, with larger academic settings using a range of products, while some are more endobariatric accounts using both the Balloon and OverStitch, likely not X-Tack due to limited applications in that setting.

Adam Maeder, Analyst

Hey, Charles, hey, Jeff. Thanks for taking the questions here and congrats on a nice year. I wanted to start with the guidance and see if we can deconstruct it a bit further, particularly by segment. I’m curious to get additional color on how you think about the ESS franchise versus the balloon business in 2022 and if you’re willing to share any contribution color from X-Tack.

Charles McKhann, CEO

Each product can continue to contribute to growth. On the balloon side, we’re still learning in terms of sustainable growth, but we are encouraged after last year. We’re not planning for another year of 50% growth, but that would be good. We believe it can be a sustainable contributor, especially with the current efforts. Regarding X-Tack, there are good opportunities in the U.S., and depending on timing of approvals outside the U.S., similar potential exists this year and beyond. We're also seeing excitement around OverStitch as we continue to add new users. Our goal remains to promote appropriately and ensure we have the right indication.

Jeff Black, CFO

As we think about our long-term growth potential, consider that OverStitch and X-Tack are likely the outsized growers, while ORBERA will probably be a bit behind that, which drives the blended growth of over 20%.

Adam Maeder, Analyst

That’s helpful color, guys. Maybe just a quick follow-up on that. Can you provide more detail on ESG and revision FDA approval timing? Is there any specific quarter where we should expect those to come on label? Additionally, does your guidance of $73 million to $75 million contemplate revenue directly associated with those indications?

Charles McKhann, CEO

When we submitted the De Novo 510(k), we posited that it typically takes around 12 months, as per analysis by our law firm. Each case is unique due to no predicate. We are mentally prepared for that timeline, placing us in the second half of the year for potential approvals. There is uncertainty, and we will do everything we can to support the process to a successful conclusion. Given that timeline, we have not included significant ramp-up in the back half of the year in guidance, though we note general awareness in the community is having a lift effect.

Adam Maeder, Analyst

Thanks so much, guys. Last question: regarding gross margin. Jeff, you provided helpful puts and takes initially. How should we think about the 2022 gross margin, considering the mid-60% target you mentioned over the next three to five years? How should we anticipate that evolution? Will it be a straight-line progression, or a bit lumpy? Can you give any quantifiable insight into 2022?

Jeff Black, CFO

As for '22, we haven't given specific guidance, but we will see margin expansion. The margin evolution will be gradual, not a quick shift. We have much to plan for regarding new product launches, configurations, and pricing. For '22 and '23, think of those as continued gradual growth.

Matt Hewitt, Analyst

Good afternoon. Thank you for taking the questions and congrats on the progress in '21. First, do you have a metric on X-Tack accounts? Looking to 2022, what’s the focus—utilization quality or grabbing new opportunities in accounts?

Charles McKhann, CEO

It's still very much about quality. We want to ensure that people understand the product well. We have a heavy focus on targeted accounts performing high volumes, and they remain a primary focus for our sales organization. While we’re also opening new accounts, our existing strategy is about focusing on utilization first.

Matt Hewitt, Analyst

As we progress through this year, will you provide utilization trends even if at a high level to help us recognize the ramp you see within accounts?

Charles McKhann, CEO

It’s a fair question. We’ll share more metrics without compromising competitive sensitivity. We try to provide sequential percentage growth, like the 40% we saw, and the increase in ordering accounts.

Matt Hewitt, Analyst

Any update on the NASH trial status in terms of timing or plans, whether it will include ORBERA or OverStitch?

Charles McKhann, CEO

We’re currently working through this. We’ve consulted experts across the GI and hepatology fields to learn from recent NASH trials. Given the numerous trials, many of which have not been successful, we’re cautious. We’re reviewing data for both products, as well as additional data that looks promising. Ongoing discussions with CMS regarding coverage policies are also critical. Given all these variables, we are taking a deliberate approach to our trial structure.

Frank Takkinen, Analyst

Can you comment on how many of your top 10 accounts are endobariatric-specific? What's driving any changes in their composition, especially regarding OverStitch and X-Tack?

Charles McKhann, CEO

The majority of top accounts are endobariatric focused, some utilizing a wider range of products. Some larger academic settings incorporate all three products, but many are driven by balloon and OverStitch very substantially.

Jeff Black, CFO

Regarding sales force growth for 2022, we ramped up to about 30 by the end of the year. We plan to focus on training for the current sales force, evaluating which programs work and which do not. You should see some hiring progress in the near term, and probably another ramp later in the year. As for investment plans following recent capital, expect to see it ramp in the operating expense as we invest in marketing, sales, reimbursement, and COGS improvement initiatives. This is largely to compensate for historical under-investment.

Ben Bienvenu, Analyst

Given the current inflationary environment and your prior comments about passing on price increases, can you provide additional timing details for those uptakes and comment on how volume growth may shift if implemented?

Charles McKhann, CEO

For OverStitch, a price increase was taken at the start of the year, which was higher due to inflation. We've implemented this effectively. Any new pricing strategies related to ESG or REVISION will be closely linked to the rollout of those products.

Jeff Black, CFO

Thanks again for joining us. We are very gratified for the progress made in 2021 and are looking forward to an exciting year ahead. Thank you for your interest.

Operator, Operator

Thank you, ladies and gentlemen. This does conclude today's conference call. You may disconnect your phone lines at this time and have a wonderful day. Thank you for your participation.