Abiomed, Inc.
Q1 2020 Earnings Call Transcript

Published: 1 Aug 2019

[Operator:]

Good day, ladies and gentlemen, and welcome to the Q1 2020 Abiomed Earnings Conference Call. At this time, all participants are in a listen-only mode. Later we will conduct a question-and-answer session and instructions will follow at that time. As a reminder, this conference call may be recorded. I would now like to introduce your host for today's conference, Ms. Ingrid Goldberg, Director of Investor Relations. Ma'am, you may begin.

[Ingrid Goldberg:]

[Mike Minogue:]

Thanks, Ingrid. Good morning, everyone. As we communicated on the last earnings call, we knew that we had some U.S. headwinds to address in Q1, following a poor performance in March due to external noise and a distraction in our internal focus. We acknowledge that the first half of fiscal 2020 was going to be more challenging, in part, due to confusion on the Impella RP letter, tougher comps at 30% growth from prior year and the normal cath Lab summer slowdown. In Q1, we implemented new training programs, organizational changes in distribution and launched external initiatives that were acquired at time to drive more growth in the future. Therefore, our outlook for the fiscal year has been adjusted accordingly. In the first quarter, Abiomed delivered $208 million of revenue, up 15% year-over-year. Operating margin for the quarter was 29.2%. Outside of the U.S. we continue to see strong performance with European revenue at 28% on a constant currency basis and Japan revenue of $8.5 million, up 227% year-over-year. We are confident in our ultimate global adoption, because we know our innovation improves clinical outcomes and patient quality of life. Abiomed is creating the field of heart recovery and this proven clinical value will ultimately transform the standard of care despite a few challenges along the way. Therefore, we continue to believe Impella adoption is a function of training, data and time. Over the last five years, the Impella product platform has been one of the fastest-growing technologies in the medical device field.

[Todd Trapp:]

Thanks, Mike, and good morning everyone. In the first quarter, we delivered revenue of $208 million, an increase of 15% on a reported basis versus a tough comparison of 36% growth in Q1 of last year. By region, U.S. revenue grew 11% to $175 million driven by a 13% increase in patient utilization. Outside the U.S., revenue was $32 million, up 50% on a constant currency driven by strength in both Europe and Japan. In the U.S. at the end of our fiscal Q1, the Impella 2.5 has been placed at 1,237 sites and Impella CP is at 1,387 sites. The Impella 5.0 is now in 605 sites and the RP is in 469 sites out of the potential 1000-plus heart hospitals. We opened up fewer sites in Q1 than historically, as we prioritized patient utilization and physician training at our existing sites.

[Operator:]

Thank you. And our first question comes from Danielle Antalffy from SVB Leerink. Your line is open.

[Danielle Antalffy:]

Good morning, everyone. Thanks so much for taking the question. Mike, I just wanted to touch on whether this could -- so I appreciate some of this is execution, but it feels like may be given the time that it's taking to drive a recovery we're at a different phase of the adoption curve a little more push versus pull? And I'm wondering if

[Mike Minogue:]

Thanks, Danielle for the question. The -- we are at a different phase. So where I would characterize is we are now moving our way through the early majority. And so if you look at the numbers 85% of our patients come from 50% of our accounts. And those accounts are driven by the physicians. So the other half of our installed-base are not utilizing Impella the way they could with the best practices. It also means that because they're using inotropes and intra-aortic balloons they're getting outcomes in shock and other areas that have been consistently in the 50% survival range. The big concern that we have with this next phase of physicians whether they're at existing centers that we're already at or whereas we go into the community is accessing closure. So you're seeing an intense focus now on the access meaning putting the Impella in and then closing the 14 French hole. And so we're doing that with education. In the PROTECT II study we have data showing that vascular complications were numerically the same between Impella and the balloon. We're doing it with clinical workshops and hands-on events like we did at SCAI. And probably the most important educational tool we have now that's been validated and is on the SCAI website is our access closure manual with videos. It was a physician-initiated educational program. And again it is now online and it was presented and it's utilized by the SCAI society which is the interventional cardiology group. So that phase that we're at is exactly -- they have a bit of a different learning curve. And as we're going back out into the communities we've shown that if folks follow the NCSI protocol which several of those hospitals are in the communities they can also duplicate those outstanding outcomes. So that's what we're focused on. And again, if I put it into formula in training data and time the access closure is really the big concern you'll find as you do your surveys. Now when we get into the ICU that has to do a little bit with the patient management and we believe SmartAssist is a big key for that. Because it allows us to have information right on the console know where the pump is and then if alarms go off people have support on-site on-call and that our Impella connect centers it's real time being monitored. For the data component, I also think we've had a recent batch of incredibly positive papers maybe so much that they're getting voted down because they're all coming together. But the first is the SCAI paper I mean this is a drastic change in survival compared to the historic norms of 50%. And again, 98% have recovery, that's cost-effective as well as it's what the patient wants. The Inova publication again showed a different unit, a different hospital system that followed the wrong protocols. But again, utilizing Impella early, they were also able to move survival from 44% to 82%. The Burzotta paper, which is actually likely one of the reasons we're seeing an increase in high-risk PCI in Europe, again shows what PROTECT II our FDA study showed that when you do a complete revascularization these patients see a permanent improvement in their EF. Then as of today announcing from our cVAD study that's prospective and it's where we also do our FDA post-approval studies that were able to minimize the rate of AKI. So, all those things together the training and the data, and as we've mentioned today, it will require a little more time to get to that next phase of users.

[Danielle Antalffy:]

Thank you so much.

[Operator:]

Thank you. Our next question comes from Chris Pasquale from Guggenheim. Your line is open.

[Chris Pasquale:]

Thanks. Todd mentioned at the early momentum you saw in April really wasn't sustained over the course of the quarter. It sounded like you're attributing that to seasonal weakness, but that would have been true in the year-ago period as well. So I'm curious at this point what drives your confidence that the RP letter is still the best explanation for the slowdown we saw in March? And if so then why haven't just the passage of time and the updated communication driven more immediate rebound?

[Mike Minogue:]

So Chris it is accurate and that the seasonal issue is true in both cases. However, the amount of organizational change and some of the external noise that was out there makes it more difficult to update folks and to drive that benefit that we did see in April. The second part of your question is the confidence we have and the RP effect is that the RP letter did come out unfortunately the process of physician letters from the FDA is they still come out with the same headline. And it wasn't until the very end of the update that it talked about the safe and affected and closed it out. So even in the update that went out there was a little bit of confusion on how it hits the web and there was a few media sources that again misinterpreted it. The second thing is that there's a lot of the initial noise doesn't necessarily get clarified. So we are making progress that's why the SCAI meeting was very important for us to have all that information there. And we did talk about it. I also think that some of these things require just a consistent period of time before people understand the context of what is a salvage patient and why are protocols so important? So we'll continue to do that. But again, we said RP letter was the biggest driver of the external noise. There was other noise that's happening around us that things do with either staging or administrative changes or just perception that's out there on the product. And so we continue to work through those as well by improving the product and also getting out the information on the clinical data.

[Chris Pasquale:]

And Mike the distribution changes that you made are those now in place, or is that a work in progress?

[Mike Minogue:]

It's both. So -- because we're expanding managing roles and because we're adding more heads we haven't been able to fill all of those yet. But from the infrastructure and from the strategy, we know that when we go into these community hospitals that are somewhat large there is tremendous upside because they again tend to be the biggest users of inotropes and balloon pumps. So we can customize the distribution in those markets. And then from a strategy perspective, we really want to incorporate the hub and spoke broader so that those sites that will set up their own systems of care have the option to transfer those patients, especially centers that do the expertise of the ICU management and bio-ventricular support. Even at existing sites, we have to get deeper so that we always have the physicians on-call and we have the heart team approach. So for that we're going to specialized training now around programs. So whether it's a high-risk Protected PCI program or whether it's a shock protocol, we're going to have to come out a little bit different for places that the physicians may have essentially require more handholding or have just a bigger concern about access and closure. And I think as you all survey users probably the number one thing you'll hear from folks that -- if they're not using it is there -- they're still just concerned with access closure. What we also remind people is with the right training and what we have that the catheter French is 14 at the French of the head, but the catheter itself is nine French. So we look at the STEMI DTU study in the 50 patients, we only had two that had vascular complications and both of those were at explant which is again a heart attack patients and we probably shouldn't have issues at explant as the patient's more stable. So, those are things we're going to do with education. But we definitely have hit a next wave of users that really are concerned about access and closure.

[Chris Pasquale:]

Thanks.

[Operator:]

Thank you. Our next question comes from Margaret Kaczor from William Blair. Your line is open.

[Margaret Kaczor:]

Hey good morning folks. Thanks for taking the questions. First one for me may be is just walking through kind of this new wider sales strategy focused on community hospitals versus going deeper into the headcount and just wanted to pick away at that in terms of how much of this was always in the plan? Even last quarter, maybe how should we assume for a new site ad so to trend throughout those here? And really how quickly can you get some of these new sites to ramp?

[Mike Minogue:]

So Margaret, the 100 of the top U.S. heart hospitals in the country, I think 99 have Impella, it might even be a 100 now. So, we've done well at the hubs. For the most part, the hub still have upside because we have escalation of patients, we have more patients that are not getting high-risk PCI. And then, we have the community hospitals our spokes. And so I think the evolution if you look at the number I provided on 85% of the patients coming from 50% that means the other 50% are actually not utilizing the technology, even though they have the same type of clinical challenges for high-risk PCI and for shock. We have best practice protocols. We have techniques and publications showing that you can get better outcomes for high-risk PCI and for cardiogenic shock. So there's no reason now that centers that the other 50% should not be utilizing Impella. And there's also extensive clinical data on inotropes and intra-aortic balloon pumps documenting that they're in some cases harmful and when used before Impella our statistical predictor of death. So we have to now evolve a little bit more, so that when we go into the community hospitals, we really focus on the access closure training. We also give them the support they need on-site. We give them the support in the ICU and as we set up the network of hub and spoke, if they have a patient that is too complicated or requires bio-ventricular support, they feel comfortable and they have the option to then transfer that patient to the hub to the center. So I think we've evolved where we've done pretty well with the hubs. We are now moving to the Phase II to get the next wave of the late majority and really those physicians are out in the community at those hospitals. And we need to do a better job there.

[Margaret Kaczor:]

Okay. And then just as a follow up maybe on guidance. If we kind of take Todd's comments, next quarter will be maybe down seasonally just a bit and imply that into the model for this quarter essentially starts to imply kind of a 14% growth for the rest of the year I think for the U.S. correct me my math is wrong on that. But how much of that is really going to be driven by comps getting easier going into fourth quarter and some of these initiatives really taking off in the fourth quarter relative to same-study progression throughout the year? Thanks.

[Mike Minogue:]

So Margaret, we're giving you full transparency of numbers that's why we've provided April last quarter's call and giving you the details this quarter. We obviously feel comfortable about what we're seeing outside the U.S. and Japan is obviously a great opportunity for us to have sustainable growth for many years. The reason we're so focused on that next phase in the U.S. is because we expect to get back a reacceleration of growth in the future, if we do see a little bit of adjustment for this fiscal year. But with the training that we're doing with the new clinical data, we expect to return to stronger growth with some of these new products, new indications, existing education. And then obviously we've got the rest of the world the new geographies outside of the U.S., Germany and Japan longer term. So we'll give transparency and you'll see what we're doing each quarter along the way. But right now, what we're really focused on is improving outcomes and remember that the way you become a standard of care, the way you drive through adoption is you just have to continue to improve outcomes for patients and make it cost-effective. And the one thing on this call and the one thing of all these new publications is they consistently reiterate that we're able to get better outcomes for patients utilizing the Impella technology.

[Margaret Kaczor:]

Great. Thanks.

[Operator:]

Thank you. Our next question comes from Raj Denhoy from Jefferies. Your line is open.

[Raj Denhoy:]

Hi, good morning. Maybe Mike I can ask you. I think one of the things that's been troubling about this slowdown that you're in right now is that when one thinks about the market sizes we've always assumed for Impella 200,000-plus in United States alone. You're still less than 15% penetrated in that. So, I guess what -- the question is really what gives you the confidence that the things you've identified whether it's expanding the salesforce this issue with access and closure are truly the pushbacks, right? Is there any other issues that maybe you're contemplating that might be behind the slowdown that potentially could be protracted here and extend even longer than maybe we're assuming?

[Mike Minogue:]

So, Raj that's a good question and something we obviously have analyzed. So, the first point I'd say is up until March, Impella has been on the fastest-growing medical device products for about five years. So, that's a signal that the market is there. Number two is we still have exclusively the FDA labels for high-risk PCI and shock. So, we're safe and effective and CMS says we're reasonable and necessary. And so those are things that come first before you get the mass production and that becomes a standard-of-care. And then as I travel around the field, unfortunately, I see a lot of centers where they are not utilizing the Impella technology or following best practices or physicians are either turning down these patients completely or trying to get in and out and in the numbers show that. So, as you look at what's the number one killer in the U.S., it's coronary heart disease. And the numbers are huge. And when you talk to physicians or even you look at your market sizes, there's a lot of great technology out there impacting the plumbing or the electricity or the valves, but in the end coronary disease is your -- it means that you have to treat the coronary arteries and there's 15 million people in the U.S. just alone with it. It causes 900,000 deaths. The Advisory Board put out a stat that high-risk procedures are projected to grow 47% over the next 25 years. This is the only area of growth for PCI. And remember that you die of organ failure which means that pump stops. And so that's where this is the highest mortality patient population. It's also why these patients are turned down treatment in the cath lab and surgical suite. So, while we go through this phase, it's also important to remember that the level of growth we had, the complexity of these patients and how sick they are, and what we've put out is our current addressable market, not the total addressable, but the current addressable market because we know that there's 700,000 people in the U.S. that have Class III, Class IV with coronary disease and low EF. Many of those are also at risk of AKI. And so we've narrowed it down to the 121 for high-risk PCI on a label that we exclusively have. High-risk PCI in itself is a first of its kind indication for Impella. And that there's additional data showing 300,000-plus patients have the ischemia and are undiagnosed. And then of the 100,000 shock patients, these are patients that are already in the hospital today. And unfortunately there's still probably 40,000, 50,000 intra-aortic balloon pumps getting used in the U.S. and there's over 100,000 patients getting inotropes every year in the U.S. So, unfortunately, this is still a clinical crisis and one of the biggest problems at hospitals. And if you even look at the latest study from Europe on just SHOCK-CULPRIT, the recent one showed that they had 50% survival in shock without Impella used up front where they just didn't do anything until after patients had already -- had lactates above 18 and were in profound shocks. So, we do feel confident. The numbers in the U.S. and the numbers outside the U.S. are incredibly conservative. And again unfortunately you do see that high-risk PCI unless you get completely revasc has poor outcomes. And for shock, unless you have a strategy to not only increase survival and drive for heart recovery, those patients have poor outcomes.

[Raj Denhoy:]

No, that's helpful. Maybe I could ask -- kind of a bit of a follow up but maybe for Todd. When you think about the new guidance of 15% to 20% for the year, how should we think about the second third and fourth quarters? I mean are you going to be towards the low end of that and then accelerate as you move through the year, or just really how should we even think about this current quarter the second quarter?

[Todd Trapp:]

Yes, well, thanks, Raj. I said in my opening remarks that typically Q2 is slightly down from Q1. So, you can do the math kind of on the year-over-year growth rate there. And then we do expect to see growth pickup in the second half of the year. Part of it is because we have easier comps. As you recall last year, second half grew a lot less than the first half. And then we have some of the new products like SmartAssist launch, which should gain traction and then some of the changes we made on the U.S. distribution structure again reducing the span of control to help really drive Impella adoption wider and deeper in some of that outside the U.S. performance, primarily Germany and Japan. So, I do think growth will pickup in the second half of the year based on those initiatives.

[Raj Denhoy:]

Great. Thank you.

[Operator:]

Thank you. Our next question comes from Matthew O'Brien with Piper Jaffray. Your line is open.

[Matthew O'Brien:]

Good morning. Thanks for taking the questions. Just real quick one upfront or two parts upfront. The proposed reimbursement changes are going to go final here in a couple of weeks. Are those incorporated, or any kind of pressure there? Incorporated in guidance for the back half? And then Todd, I think the utilization rate of U.S. Impella was actually higher than the actual growth rate. Was there a little bit of pricing pressure in the quarter? Then I have one follow-up.

[Todd Trapp:]

So, I'll take the U.S. patient utilization. So, yes, utilization was up 13% in the U.S. Our revenue growth rate was up 11%. The big driver there is that we opened up fewer sites in the quarter. So, if you went back and look at the average sites, we opened up the last four quarters was roughly 120 sites. We opened up 62 sites in the quarter. And that impacted our revenue on a ballpark of about $3 million, which translates to about 2% revenue growth. So it was really just the lower side openings in Q1.

[Mike Minogue:]

And Matt, this is Mike. So on the question CMS update will be coming out the guidance does take that into account. And as we've communicated in the past, we just always want to make sure that CMS has the accurate hospital charges based on all the changes that have been made in DRG 215 over the last three years.

[Matthew O'Brien:]

Okay. That's helpful. Thanks Mike, and then the follow-up questions on the business going forward. Japan's doing really well. Europe's still growing nicely. It seems like there's a little low right now in the U.S., which is fixable. But I think what a lot of investors are trying to get their minds around is historically you talked about 25% to 30% top line growth. Are you guys more of kind of a 15% to 20% consistent top line grown over multiyear period going forward?

[Mike Minogue:]

So Matt, we've only given the forecast for this fiscal year. But we do expect to go back to be a better -- one of the better growing medtech companies. Obviously a lot of the numbers we've been getting bigger over the last five years. But again, I think that we now have half of our population that has incredible upside. We essentially got in a critical mass. We're in the all heart hospitals, but what we need to do is get with more physicians at those centers and at those community hospitals, we need to establish programs not one-off users. And so that's what -- you're going to start to see a little bit of shift, which means that there is upside. And then longer term, we do have the Impella 5.5. We do have some of the improvements coming on the expandable sheaths for the Impella CP, which will innovate a way the concerns of access closure. And then we have also new geographies along with the new publications and new studies that would be entirely new population. So that's what we're focused on. We, again, always try to adapt and execute and be very efficient in both being a top grower, but also disciplined business that delivers an ever improving net income.

[Matthew O'Brien:]

Fair enough. Thank you.

[Operator:]

Thank you. Our next question comes from Jayson Bedford from Raymond James. Your line is open.

[Jayson Bedford:]

Hi. Good morning. Just a couple of quick ones. Just on the U.S. growth. Is the slowdown widespread across your entire customer base, or you're seeing slower growth on a specific segment of the user base? You mentioned community hospitals a few times. I'm just curious if there's a trend here from a user standpoint?

[Mike Minogue:]

Jayson, that's a good question. As again as you imagine since we collect data on nearly every commercial patient by hospital by name, we can review that weekly daily and we do. It is not widespread. It's essentially around 25% of in-pockets where they're flat to slightly down. And then the other part of the country has -- continues to see the kind of growth rates that we've been putting up historically. So we've got ways to address the areas that are down, some of those areas are better alignment for the distribution. Some are more heads and some have had potentially open spaces or turnover or physicians have relocated that have been bigger champions for us. So that's where we're really focused on. And to simplify it's an organizational design that allows us to go into those pockets and build the programs themselves.

[Jayson Bedford:]

Okay. That's helpful. And then just secondly, did you mention growth in high-risk PCI in shock? I apologize if I missed it.

[Todd Trapp:]

Yes. We did. So growth in high-risk PCI in the quarter was 12% and for shock it was 14%.

[Jayson Bedford:]

Thank you.

[Operator:]

Thank you. Our next question comes from David Lewis from Morgan Stanley. Your line is open.

[David Lewis:]

Great thanks. Just a couple of questions. Mark, just first off. Your PCI was weaker last quarter, shock was much weaker this quarter. And these businesses have similar commercial channels, but very different end-markets. So any thoughts on why we've seen weakness in both in these last two quarters?

[Mike Minogue:]

Yeah. So David so I would go through and analyze both the quarter, but I'd I also look at it by month. So in the Q4, we saw March fall down primarily on high-risk PCI not necessarily in shock. And then in April we saw a rebound of 17% overall, but we saw 16% for high-risk PCI growth and 20% for shock. So that April looked like we had adjusted enough to see already an immediate impact. But again as we got into the summer months, even though it's consistently year-over-year with the changes, with some of the noise it didn't hold up in June, and so that's one of the things we're looking at. And if I look at Q4 to go back to where we were, again you were still seeing pretty much higher January and February months relative to high-risk PCI and shock themselves. And so I think that's the learning curve for us is understanding where were we down? Why were we down? Because we do have areas that haven't been very significant growth in high-risk PCI around the U.S. And what's interesting is with the Dr. Burzotta paper from Europe, we're seeing a nice lift in high-risk PCI in Germany, which historically had been more for shock market for us. And then, of course, we've got -- always have pockets of extreme growth in new areas where we've invested. So those are the things we're looking at, measuring where that territory is relative to the adoption curve. But we're doing exactly the analysis that you're talking about.

[David Lewis:]

Okay. And just a follow-up and a quick one for Todd. Just my-follow up for you Mike is just that dynamic of large center traction getting more challenging. Are you seeing that equally in PCI and shock? And then for Todd, to deliver the top end of the guidance or math it's the momentum stability at the top-end. So the real question is you talked about April trends. How did July trend? Thanks so much.

[Todd Trapp:]

Yeah. I mean David we're not going to start giving out monthly revenue by high-risk PCI and cardiogenic shock. I will tell you that, we factored in the guidance of 15% to 20% based on how we exited Q1. And what we've seen so far in July.

[Operator:]

Thank you. Our next question comes from Chris Cooley from Stephens. Your line is open.

[Chris Cooley:]

Good morning and appreciate you taking the questions. Just two quick ones for me at this point, maybe either for Mike or Todd. Is -- does the increased focus on the community hospitals here in the United States, any way shape or fashion alter your views on continued geographic expansion outside of your primary markets in Germany and Japan? And then just as a follow-up I'm just asking both here in succession. I'm curious Mike you're talking about growing utilization community hospitals and the focus there really being on education. But there's always been a very large clinical body of evidence in support of Impella utilization. So I'm curious if you think it's really an education focus here, or is it an economic understanding both from an episodic standpoint of the procedure but also maybe from a continuing perspective at that community hospital level? And as a result if its the latter, does that really mean that we need to see DRG 215? And it's revised or whatever it may be rate of reimbursement first before you can really make a big push there that's sustainable? Thank you.

[Mike Minogue:]

So, Chris, lot of questions there, I'll do my best to hit all of them. And I'll ask for clarification if I miss it. The first one is the increased focus on the community hospitals and how does that affect outside the U.S.? The answer is, it always has and it was part of our planning process. Since we have this infrastructure in the, United States, that allows us to provide this support in the ICU, on phone and now with Impella Connect. It allowed us to see the importance of protocols, but also the importance of us being able to touch them even over the phone. And because we know from our internal data that we have an impact, and we improve outcomes in the IQ database. As we've been waiting to plan the season go around the world, one of the keys to that success is establishing training centers in the countries, and then bringing something like, SmartAssist onto the console itself. So every time the patient is being supported, the console itself with the optical sensor and the information lets the physician and the nurses know where the pump is, how it's doing and how it's working with the heart. And also most important it allows us to wean appropriately. So SmartAssist really does make the management, the implantation much easier. And then what you're seeing in the next phase of this is as we bring Impella Connect over the top which is the real-time monitoring online. And so, we announced today that we received Impella Connect approval in Japan. And you're going to see us roll it out in Japan, so that countries like Japan, where we have the smaller number or other countries that we launch into, will be utilizing Impella Connect to monitor their patients real-time to capture data, to give benchmark analysis back to the hospital, so they can continue to improve their outcomes. And also make ourselves more productive in the training process. At a high level what that means is, instead of selling a product or focusing on at one patient at a time or procedure, we're really going to establish programs, where people are getting a feedback loop on their outcomes. And we're looking at some of the best practices weather is high-risk PCI or shock. So that's the first part of your question. Your second question has to do with the, the education level based on the quality of the data. And you mentioned that -- or is it an economic means so are we waiting for the DRG 215. So what I would say for that is, Impella first of all, if you recover somebody's heart and you increase survival, you're talking about one of the most cost-effective applications in medtech. So, sending Soma, our patient home with their own heart, that's United Healthcare. That's a million-dollar patient in hospital charges in the next six to 12 months. So its such an important thing to be cost-effective. But in our case, this is life or death. And the quality of life measurement, from a CMS again is reasonable and necessary. On the regulatory side, there is also a mandated protection or liability in treating shock patients because of their risk factor. The FDA, safe and effective label, allows our hospitals in our physicians to know that a regulatory body has validated this technology. And that to me is one of the most important components of our data. However, we continue to need to do more publications, more studies and in the space of science you can never have enough studies. And there's always room for improvement. And there's always room for more exploratory investigations. And that's where we are. A lot of times investors after reading all the clinical papers, will say to me, "How can it take so long? This is obviously the clinical data is very positive". And sometimes I remind them that they've already now read more information and more clinical papers that many of the physicians. Just because the burden of work that's on the physicians, the lack of time they have, in order to just do research and study. Because they're so deep and they've got so many different specialties. And so a lot of times we just have to continue to take these summaries of our studies and simplify them. And today I'd say that, there's many people that still are not aware of all the details even from our FDA studies, such as PROTECT II or some of the NCSI data. And so that's up to us to do a better job.

[Chris Cooley:]

Thank you.

[Operator:]

Thank you. And I am showing no further questions from our phone lines. I'd now like to turn the conference back over to Mike Minogue for any closing remarks.

[Mike Minogue:]

Thank you everyone for your time today. We appreciate the questions. And if you have any follow-up please feel free to reach out to us directly. Have a great day.

[Operator:]

Ladies and gentlemen, thank you for participating in today's conference. This does conclude the program. You may all disconnect. Everyone, have a wonderful day.