Earnings Call Transcript - SIBN Q2 2023

Operator, Operator

Good afternoon, and welcome to SI-BONE's Second Quarter Earnings Conference Call. At this time, all participants are in listen-only mode. We will be facilitating a question-and-answer session towards the end of today’s call. As a reminder, this call is being recorded for replay purposes. I would now like to turn the call over to Saqib Iqbal, Senior Director of Investor Relations at SI-BONE for a few introductory comments. Sir, please go ahead.

Saqib Iqbal, Senior Director of Investor Relations

Thank you for participating in today's call. Joining me are Laura Francis, Chief Executive Officer; and Anshul Maheshwari, Chief Financial Officer. Earlier today, SI-BONE released financial results for the quarter ended June 30, 2023. A copy of the press release is available on the company's website. Before we begin, I'd like to remind you that management will make statements during this call that include forward-looking statements within the meaning of federal securities laws which are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. Any statements contained in this call that relate to expectations or predictions of future events, results or performance are forward-looking statements. These forward-looking statements are based on the company's current expectations and inherently involve risks and uncertainties. These risks include the impact on SI-BONE’s ability to introduce and commercialize new products and indications, SI-BONE’s ability to maintain favorable reimbursement for its products and procedures, the impact of potential economic weakness on the ability and desire of patients to undergo elective procedures, SI-BONE’s ability to manage risk to supply chain, the impact of future capital requirements driven by new product introductions and risks to the continued renormalization of the healthcare operating environment. Other forward-looking statements include our examination of operating trends, and our future financial expectations, such as expectations for surgeon training and adoption, active surgeons, new products and clinical trial enrollment, and are based upon our current estimates and various assumptions. These statements involve material risks and uncertainties that could cause actual results or events to materially differ from those anticipated or implied by these forward-looking statements. Accordingly, you should not place undue reliance on these statements. For the list and description of the risks and uncertainties associated with our business, please refer to the risk factors section of our most recent Form 10-K and form 10-Q, filed with the Securities and Exchange Commission. SI-BONE disclaims any intention or obligation, except as required by law, to update or revise any financial projections or forward-looking statements, whether because of new information, future events or otherwise. This conference call contains time-sensitive information and is accurate only as of the live broadcast today, August 7, 2023. With that, I'll turn the call over to Laura.

Laura Francis, CEO

Thanks, Saqib. Good afternoon, and thank you for joining us. I'm pleased with our performance in the quarter as we delivered over 30% revenue growth led by robust demand for our portfolio of solutions, strong surgeon engagement, and favorable reimbursement tailwinds. The US procedure growth trends over the last several quarters give me confidence that we're well-positioned to deliver a strong second half of 2023. Furthermore, our strong liquidity position, bolstered by the successful capital raise in May, provides us the flexibility to continue our judicious investments, portfolio expansion, and commercialization initiatives. We believe these investments combined with secular growth factors in the business will allow us to deliver continued revenue growth and accelerate our progress toward adjusted EBITDA and cash flow breakeven. Before I discuss our results, I want to thank our employees as they've continued to demonstrate unwavering dedication to serve our expanding surgeon base and ensure patients have access to our best-in-class solutions. This level of consistent record performance over the last several quarters would not be possible without you. Now moving to our second quarter performance. In the second quarter of 2023, we generated record worldwide revenue of $33.3 million, an increase of over 30% compared to the second quarter of 2022. The quarterly result was led by record US revenue of $31.2 million, which represents US revenue growth of over 31% compared to the prior year period. This fifth consecutive quarter of record worldwide revenue and improving operating leverage exemplifies the consistency of our execution and strength in the business. Now, let me provide an update on our key initiatives as we continue to look to extend our leadership position and drive strong long-term growth. Starting with sales infrastructure, our direct sales team is our biggest asset as we expand our product portfolio and surgeon base. At the end of the second quarter, our US commercial organization comprised 85 quota-bearing territory managers. We complement our territory managers with clinical support specialists, as well as a growing network of third-party sales agents for case coverage. We also selectively placed instrument sets in high-volume hospitals to meet demand. We're confident that our hybrid strategies will allow us to further penetrate the surgeon market cost-effectively, accelerate top-line growth, and achieve higher productivity. At the end of the second quarter, our trailing 12-month average revenue per territory in the US was approximately $1.4 million, representing a 32% productivity gain over the comparable trailing 12-month period. Our strong revenue growth and increased operating leverage over the last several quarters are the results of our investments in building a world-class commercial organization. Moving on to surgeon engagement, we exited the second quarter with approximately 935 active surgeons. This equates to approximately 30% growth in our active surgeons over the second quarter of 2022. This was the 10th consecutive quarter of double-digit year-over-year growth in active surgeons. Based on early third quarter trends, we surpassed the 950 active surgeons milestone we set at the end of the first quarter. It's also encouraging to see surgeon overlap across our procedures. We expect our complementary portfolio to drive deeper engagement and increase procedures per surgeon over time. These trends and active surgeon base reaffirm that our portfolio expansion strategy and investment in education are resonating with our customers. On academic training, we're pleased to see steady adoption of our procedures by surgeons first trained in residency and fellowship programs, as they matriculate to independent practice. For example, among the cohort of surgeons first trained as residents and fellows, procedure revenue in the second quarter of 2023 nearly doubled compared to the second quarter of 2022. Turning to products and solutions with iFuse 3D, iFuse-TORQ, and iFuse Bedrock Granite, the value of our innovative, versatile, and complementary product portfolio has positioned us as the top choice for surgeons looking for safer pelvic solutions. iFuse-TORQ has become a key growth driver for us due to its expanded clearance, covering SI joint dysfunction, trauma, and adult deformity. iFuse-TORQ provides a complementary technology to iFuse 3D for our existing surgeons. It's also allowed us to engage new surgeons and successfully convert several surgeons using competitor products when performing minimally invasive SI joint fusion procedures. While we remain strong advocates of the lateral transiliac trajectory as being the gold standard when performing SI joint fusion procedures, in June, we received FDA clearance for placement of iFuse-TORQ in the posterior lateral trajectory. This clearance provides surgeons, mostly those who are competitor conversions, the flexibility and confidence to use their preferred approach. The use of iFuse-TORQ as the second point of fixation across the SI joint and adult deformity procedures is increasing since the product received FDA clearance for the bedrock trajectory last year. In trauma, we remain in the early stages of market development and are encouraged by the adoption we're seeing for iFuse-TORQ in sacral insufficiency fractures. The trauma opportunity is of strategic importance to us as the sacred pelvic solutions leader and is an important avenue for growth over the long term. Moving to iFuse Bedrock Granite, we are extremely pleased with the success of Granite in its first full year on the market. This breakthrough device has allowed us to target 130,000 annual cases across long-construct adult deformity procedures and degenerative spine procedures to the sacrum, expanding our total addressable market by approximately $1 billion to over $3 billion. Given the positive surgeon reception, we're actively rolling out instruments and implant sets to capitalize on the demand momentum for Granite. Furthermore, in June, we expanded the Granite implant family with the launch of a Closed Head Granite implant. This addition to the Granite family will allow us to drive adoption with a subset of surgeons who prefer implants with a closed head to attach to the rod. We believe Granite has the potential to become the standard of care for stabilizing the base along construction in adult deformity procedures, and this addition ensures that Granite can address the preferences of surgeons performing pelvic fixation procedures. In addition to the use of Granite in long-construct adult deformity procedures, we are encouraged to see that year-to-date, nearly 40% of the procedures in which Granite is used are actually shorter multilevel constructs, generally a treatment for degenerative spine disorders. Given the demand trends, and over 100,000 annual procedures involving spinal fusion to the sacrum, we're progressing toward a 2024 launch of another new product in the Granite family. We believe the new product will further accelerate adoption of Granite in these short construct procedures. Along with the growing demand for Granite, we're seeing a consistent trend in surgeons using some combination of our products with Granite to achieve two points of fixation across the SI joint on either side in long-construct procedures. This is driving a significant pull-through opportunity for the portfolio, and a higher per-procedure average selling price. Moving on to clinical evidence, given the growing interest in the SI joint space as a market leader with a commitment to clinical evidence and patient safety. We launched the STACI study in June. STACI is a prospective study of the use of iFuse-TORQ in patients with sacroiliac joint dysfunction. The purpose of the study is to work with a select group of physicians and gather post-market information on the use of iFuse-TORQ for sacroiliac joint fusion. I'll now turn the call over to Anshul to provide more detail on our financial results.

Anshul Maheshwari, CFO

Thanks, Laura. Good afternoon, everyone. I will focus my comments today on second quarter revenue trends, operating leverage, liquidity, and end with our updated 2023 guidance. Starting with our second quarter revenue, as Laura noted, our worldwide revenue in the second quarter was $33.3 million, representing growth of over 30% compared to the prior year period. Second quarter US revenue was $31.2 million, increasing over 31% compared to the prior year period. This record US performance was driven by growth in procedure volumes, which rose by approximately 30% compared to the prior year period. In addition to robust volume growth for the second consecutive quarter, our US procedure average selling price increased compared to the prior year period. International revenue was $2.1 million, reflecting growth of approximately 15% compared to the prior year period. Across Europe, France maintains strong volume growth, offset by ongoing recovery in Germany and the UK. Moving to gross margin and operating leverage. In the second quarter of 2023, our gross margin was 81%, in line with our expectations, as anticipated. The gross margin reflects the impact of procedure and product mix, due to higher total cost of iFuse-TORQ and Granite, an increase in depreciation from the deployment of instrument trays to support the growing demand for these products, depreciation associated with a second facility in Santa Clara, and higher freight costs. Operating expenses were $38.9 million in the second quarter of 2023 versus $40 million in the prior year period. This 3% decrease in operating expenses is mainly due to the timing of certain commercial activities that are scheduled for the second half of 2023. This was partially offset by an increase in stock-based compensation and higher commissions associated with the revenue growth in the second quarter of 2023. We're pleased that we have now demonstrated several consecutive quarters of improved operating leverage while investing in R&D and clinical research, which are crucial to delivering strong and sustainable revenue growth over time. Our net loss was $11.2 million, or $0.30 per diluted share for the second quarter of 2023 compared to a net loss of $18.5 million, or $0.54 per diluted share in the prior year period, representing a 46% earnings per diluted share improvement. The earnings per diluted share for the second quarter of 2023 are also impacted by the increase in the number of shares outstanding from a follow-on common stock offering in May. Adjusted EBITDA loss in the second quarter improved 59% to $4.7 million versus $11.5 million in the prior year period. Turning to liquidity, we ended the quarter with a strong balance sheet, including approximately $169 million in cash and marketable securities. Our cash balance includes approximately $84 million in net proceeds from the follow-on offering in May. Our first half cash used in operating activities was $14.3 million, an improvement of nearly 50% compared to $28.4 million in the prior year period. We are pleased with our trajectory of cash utilization in the last few quarters while continuing our investment in long-term growth initiatives. Additionally, we are building our instrument trays and inventory capacity to support the growing demand for Granite as we prepare for a seasonally strong fourth quarter. Finally, moving to our updated guidance for the year. Based on our second quarter performance, we are increasing our full year 2023 worldwide revenue guidance and tightening the range to $132 million to $134 million, up from a previous guidance of $128 million to $131 million. This revised guidance translates to year-over-year growth of approximately 24% to 26% versus the previous range of 20% to 23%. We continue to expect the 2023 annual gross margin to be approximately 80%. Based on the updated guidance, we anticipate operating expenses will increase in the mid-single digit percent for the full year 2023 due to anticipated higher commission and bonus expenses from higher revenue. With that, I will turn the call over to the operator for questions.

Operator, Operator

Our first question will come from Craig Bijou of Bank of America.

Craig Bijou, Analyst

Good afternoon, thanks for taking the questions, and congrats on another strong quarter. I wanted to start. I know you're typically reluctant to give details on specific products, but I'm going to try anyway. And I want to see if there's any color that you can provide on the strength in the first half. And then looking at revenue guidance, even with the raise, it implies, essentially, flat revenue first half versus second half, maybe slightly more in the second half. So is there anything on the product level that we should be thinking about which suggests that the strong first half growth that you saw will continue in the second half?

Laura Francis, CEO

Thanks, Craig, for the question. I'll start by addressing your first question regarding our product performance, and then I will let Anshul provide more details about our guidance. We are very pleased with the quarter we just completed, achieving 30% growth, strong ongoing momentum in the US, an expanding active surgeon base, improved average selling prices, and a 60% reduction in our bottom line losses. We are excited about our quarterly performance and see robust momentum continuing into the second half of the year, which is why we confidently raised our guidance. From a product standpoint, we are experiencing solid performance across the board. Our core business, particularly primary SI joint fusion using either iFuse 3D or iFuse-TORQ, continues to drive our results. Additionally, our trauma segment is gaining traction with iFuse-TORQ, especially concerning sacral insufficiency fractures. Lastly, we’ve had a successful launch with Granite, creating a lot of enthusiasm around it. We also introduced the Closed Head Granite product towards the end of the second quarter, which opens new opportunities with specific surgeons who favor that particular option. While I won’t break down the specific growth figures, I can say we are seeing positive growth in all areas I've mentioned and are optimistic for the second half of the year.

Anshul Maheshwari, CFO

And, Craig, to answer your question on guidance. So what Laura was talking about some of the enthusiasm in the business that we've seen not just in the first half, but also the second half of last year. And we've had about five quarters now of record revenue. And obviously, this first half of the year is actually the strongest sequential growth and year-over-year growth we've seen as a public company. So feeling really good about how the business is set up, some of the assumptions that we have made in our guidance, and the last increase in guidance we did at the end of the first quarter have played out better than what we anticipated both in terms of the Granite adoption, the rollout in the ASP trends. Now while all that's been going on, we also, while being very confident of the strength and the secular trends in the business, ultimately acknowledge that there's potential seasonal strength in the second half. We just want to be very thoughtful as we're going into the back half of the year, and that's sort of reflected in our guidance. And some of the assumption changes that we had provided some more upside from the Granite rollout in the second half. And historically, we've talked about mid-single digit ASP decline, and even though we had two consecutive quarters of positive ASP, we're still assuming ASP pressure in the back of the year, albeit low, single digit now. So we think it's appropriately hedged in terms of getting into the second half of the year.

Craig Bijou, Analyst

Got it. Thank you. And just a quick follow-up, Laura, I think you said the new approval for TORQ better positions you to go after some of those competitive cases that the SI joint fusion that may prefer the screw versus the triangular implant iFuse. So maybe if you just expand a little bit on that and talk about how you are doing, picking up those competitive cases? Thanks.

Laura Francis, CEO

Sure. And TORQ, as you know, is primarily launched to focus on the trauma opportunity that we have with sacral insufficiency fractures. So that continues to be a long-term opportunity for the business that we're really excited about, another adjacent market. Our best estimate is around $350 million of potential there as well. But the more immediate opportunity with TORQ certainly has been in the primary minimally invasive SI joint fusion market. And so we've seen a very significant uptick of competitive surgeons that are converting over to iFuse technology using the TORQ implant. And some of those surgeons have provided feedback where they're actually interested in the lateral approach, but they're also interested in the posterior lateral approach. And what we want to do is we want to be the company that provides sacral and pelvic solutions, regardless of what the surgeon is interested in. And so while we remain strong advocates of the lateral approach, which is the gold standard, there's a lot of data out there showing the efficacy of the product using the lateral approach. We also want to give those competitive surgeons the solution that they're looking for, and the confidence to use it so that trajectory is now on label.

Young Li, Analyst

All right, great. Thanks for taking our questions and congrats on a strong quarter here. I was wondering if you can maybe share some more color on the inter-quarter growth. It sounded like the momentum carried into July as well. But what are some of the expectations for the summer season? Are there seasonality impacts, and can you provide some color on this high-level Q3, Q4 cadence?

Anshul Maheshwari, CFO

Yes, hey, this is Anshul. One, I think this question, so obviously, coming out of the second quarter, or the first half of the year, we feel pretty good about the business. And some of that is thoughtfully reflected in our increased guidance of 24% to 26%. When you think about quarterly trending sequentially in the third quarter, historically, you see, as an industry, a sequential dip in the third quarter from the second quarter can be somewhere in the low single-digit range. And in our guidance, that's what our assumption is: that sequential decline for Q2 and Q3 is mainly driven by this summer seasonality and actually having one less selling day in the quarter compared to the prior quarter, while continuing to acknowledge that we've got strong momentum in the new product rollout. And we're going to work hard to minimize the impact of that, but that's not incorporated in the guidance that we've set.

Laura Francis, CEO

Yes, thanks for the question, Young. So in this dovetail a little bit with your previous question on inter-quarter growth in July, we did mention in our prepared remarks that we have actually exceeded the high watermark of 950 surgeons in Q1 already at the end of July. So we did see some strong new surgeon growth heading into the month of July, which is very encouraging, given the summer months. I do believe that you are right that we have seen a decrease in the amount of time it takes for us to bring on new surgeons, and part of it is just that the procedure is more well known at this point in time. And part of it is the different modalities that we can use in order to reach the new surgeon. So it can be a regional course with canal lab training; it can be a local training course in the OR, or it can be with our simulators, which we still are heavily using. And that's on the core primary SI joint fusion business. If you actually look at our Granite business, it's actually quite easy to go in. And we do what we call an instrumentation review, typically in the Office of the Surgeon, because this is a procedure that they're used to doing already, they're just going to be using the Granite technology, that's replacing some of the existing technologies that are out there. So in terms of adding active surgeons, I do believe that we have a number of different ways to engage these new surgeons, and that we have significantly improved our ability to onboard.

Kyle Rose, Analyst

Hi, great. Thanks, everyone. And congrats on a strong quarter. Wanted to just have a look, you've had the entire out-of-market growth over nine months now. Just wanted to see if you've seen material changes in the amount of plans used for procedures. There's been a lot of talk of going to the potential for or somewhere along that path. And then secondly, I don't know if I missed it. Did you get the number of CFS reps you have in the field as well?

Laura Francis, CEO

Sure, thanks, Kyle, for the question. I will address the topic of the end cap. Just to remind everyone on the call, we have an end cap of slightly over $98,000 for Medicare cases, exclusive to Granite, which gives us a significant competitive advantage, especially when combined with the product's effectiveness. Surgeons aim to prevent fixation failure in long-construct cases, which can average a cost of a couple of hundred thousand dollars for the initial case and about $125,000 for revision, significantly impacting patients as well. The end cap is economically advantageous for the surgeon, hospital, and payer, and we've observed strong interest in this particular end cap. Regarding our CFS reps, we used to present both numbers, which caused some confusion, especially with the push for agent sales. Typically, the ratio has been just under one CFS for each senior quota-bearing rep. We're also adding more agents who are boosting productivity, which has seen a 32% increase over the past year compared to the previous year. In terms of growing territory rep productivity, we have increased from less than a million in 2021 to around $1.4 million now. The quota-bearing reps are supported by the CFS and the addition of agents, particularly valuable for Granite cases.

Samuel Brodovsky, Analyst

Hi, thanks for taking the questions. Just the first one. And thanks for the color around the certain dynamics to start Q3. With new TORQ, should we think about a steady cadence of new competitive surgeon conversion through the second half? And or is that more of a one-time thing? And how should we think about what's contemplated in guidance in terms of new surgeon adds?

Anshul Maheshwari, CFO

Yes, in terms of new surgeon ads, it's not just the posterior lateral project with TORQ. We're really focused, as we have been able to the last several years through education and engagement to continue to grow that number. And it's really critical for us as we think about the long-term outlook for the business. And based on what we've seen thus far, the quarter, we feel pretty confident that we will continue to hit new active surgeon milestones throughout 2023 at the end of each of the quarters. And right now, our expectation is to have that low to mid-teens growth in the fourth quarter of 2023 compared to the fourth quarter of 2022, which as you may recall, Sam was a pretty high watermark to start with at the end of last year. So we feel very good about that. The other piece that is also equally important for us is continuing to focus on growing surgeon overlap. Laura talked about the multiple modalities and treatment types that we're engaging surgeons with. And we've had a lot of success there, and we've seen a 30% growth this quarter in active surgeon base for our procedures performed by surgeons who have stayed flat. So you've actually had surgeons moving up the volume scale as well that have been doing a procedure for a while. So both of those metrics are pointing in the right direction for us. Yes, Sam, on the ASP side. Look, we're really encouraged by the ASP trends, specifically in the first half, having had two consecutive quarters of year-over-year ASP improvement. And it's driven by two things, right. The first one is the Granite volume that Laura has talked about, where we've seen surgeons, specifically those that do adult deformity procedures using more than two points of fixation, so more than two SI-BONE implants in their procedures. And to some extent, we are also seeing a bit more moderate decline in ASP within the minimally invasive SI joint fusion business, even though we've continued to see a move to ASCs. And historically, that decline has been in the mid-single digits at the ASC side of service. But with the increase in the fees in the start of 2023, the team has actually done a great job and worked really hard, and in several cases, been successful in maintaining that pricing on those contracts. But we also want to acknowledge it's been only two quarters, right. And while we feel good about some of the reimbursement tailwinds and the procedure product mix, we just want to be thoughtful in not incorporating that upside in the back half of the year, or at this point, it’s too premature to talk about 2024.

Andrew Ranieri, Analyst

Hi, Laura and Anshul. Thank you for addressing the questions. First, regarding operating expenses, you've performed well year-to-date; leveraging these expenses is becoming increasingly important. In your comments, you mentioned ongoing revenue growth and progress towards achieving adjusted EBITDA and cash flow breakeven. I would appreciate it if you could elaborate on these two aspects and share your expectations for establishing the foundation to ultimately reach these targets for adjusted cash flow and EBITDA breakeven.

Anshul Maheshwari, CFO

Thanks for the question. In terms of the operating leverage, we're really pleased with the trajectory that we've demonstrated in operating leverage; it's been pretty linear to our top line growth. And it's basically driven by the foundation that we've built in making investments that we knew were required to support the level of growth acceleration we're seeing in the business. Now, in terms of how we see that evolve, we do believe that fiscal year 2023, we will continue to see operating leverage, albeit the year-over-year comps toughen a bit. And you are seeing that in last year as well. But we feel good about that. And we're not going to be giving up guidance on when we believe we get to breakeven from an adjusted EBITDA or cash flow perspective. But if you look at the trajectory that we've been on, and extrapolate where revenue has been and is potentially going to go when we provide guidance for 2024 and beyond, we'll be able to share more.

Laura Francis, CEO

Thanks, Drew. On Granite trays, the Granite launch really has been trying to supply in order to meet the demand. And I talked in my prepared remarks about the efforts of our team in order to hit the results that we've hit. And this is a particular area that I would say people have gone above and beyond here. So our operations team is trying to supply the implants that are needed, the trays that are needed, and then the people in the field trying to utilize the trays that they have. It has not been unusual for our sales reps to have to drive hours in order to retrieve trays and actually go to another site. And so what we think we're doing here in the second quarter and in the third quarter is making sure that we have the inventory that we need, especially for Granite, as well as the trays that we really need particularly going into the seasonally high-volume fourth quarter that's coming here. And we feel very confident that we're in that position. But it really has been around 12 months of a lot of work in order to make sure to meet the demands that our surgeons are providing.

Operator, Operator

Our next question will come from the line of David Saxon of Needham & Company.

Unidentified Analyst, Analyst

Hello, this is Joseph on for David. Maybe a high-level question. Looking at 2024, Anshul, I know you said it was maybe a little early to comment on it, but maybe some high-level details. You'll be facing much more difficult comps in 2024, but you will also be farther along with the Granite and TORQ rollouts. And the assumption that you have shorter comps for Granite launch, they're going well, but just wanted to hear how you guys are feeling about sustaining that 20-plus growth, even if you start lapping those tougher comps.

Anshul Maheshwari, CFO

Yes, Joseph, thanks for the question. Our execution over the last several quarters gives us a lot of confidence in the underlying momentum in the business, the foundation of which is built on our differentiated portfolio, which as you highlighted is the next family of Granite products that we will launch next year, the favorable reimbursement both within the SI joint fusion side of the business, as well as the end cap on Granite. And just the improving operating leverage try to, we are set up really well. We do believe we're in the early innings of delivering on our long-term growth strategy that we've laid out over the last couple of years and have all the ingredients in place to deliver strong and sustainable as well as fiscally responsible growth. But that said, we don't want to get ahead of ourselves. I want to make sure we can capitalize and deliver what we believe will be a strong second half before we talk about 2024. So it’s too early for me to give you numbers on 2024 at this point, but we're doing everything possible to deliver on a strong second half and feel good about that.

Laura Francis, CEO

Yes, I'm happy to take that question. The digital marketing activities have been a focal point for us, we are trying to generate additional knowledge with patients of SI joint dysfunction and degeneration. We've been quite successful in doing that, whether it's bringing patients to the website, completing our pain survey, or using our Find a Doctor functionality in order to be referred to one of our surgeons. We've been quite successful in using search as well as social media to drive patients to a better understanding of this particular condition. Now, what we're really doing is we're starting to focus a little bit lower in the funnel. And so for those patients who have actually had an interest in finding a doctor to help to further facilitate that process, as well. So our marketing strategy is evolving here as we continue to develop our digital marketing strategy.

Operator, Operator

Thank you. I don’t see any further questions in the queue. I would now like to turn the conference back to Miss Laura Francis for closing remarks.

Laura Francis, CEO

Thanks to all of you for joining the call today. The year-to-date performance and favorable demand trends bolster my conviction in a strong second-half performance as well as our long-term outlook for the business. I’m confident that we have all the elements in place to deliver strong and sustainable long-term growth and progress toward profitability. So thanks for your time today. Goodbye.

Operator, Operator

This concludes today's conference call. Thank you all for participating. You may now disconnect and have a pleasant day.