Boston Scientific Corporation (BSX) Earnings Call Transcript & Summary

Okay. Good morning, everyone. Thanks for joining us on day 2 and I'm super excited to kick day off with the Boston Scientific. We have from the company, Dave Pierce, who heads their -- President of Endoscopy; Dr. Brian Dunkin, the Chief Medical Officer of Endoscopy; and of course, Lauren Tengler, whom all of you know, who's heading Investor Relations at Boston. Dave, Brian and Lauren, thanks for taking the time this morning with us.

Thanks, Vijay.

Absolutely.

Nice to be here.

Fantastic. So I do want to get that one near-term question out of the way, Lauren, before we focus on the business. A lot of questions around Omicron and shutdowns, restrictions in EU. Maybe at a high level, your guidance, I think, for Q4, 6% at the midpoint, assume no improvement versus 3Q trends. I mean in hindsight, that seems to have been a smart move. I'm curious how you guys are seeing the latest wave and thoughts on Q4 trends?

Yes. So trends in the U.S. for October and November have improved from the peak in September of Delta, and we continue to be impressed with hospital systems and their ability to really manage through this difficult situation.

And just on lockdown restrictions in Europe. Is that a new phenomena that you're contending with?

Yes. So when we put that wide guidance range for Q4 that you just mentioned, we really wanted to contemplate kind of all outcomes or a broader range of outcomes from both COVID and staffing shortages. And so that's really the driver behind that wide range. Within Europe, we are seeing some pockets of impact, but they've been managing it well thus far.

Understood. And just, Lauren, last one on this topic. Could you remind us of where we were exiting 3Q on utilization levels versus pre-pandemic? I want to put that October-November in context.

Sure. So we didn't give precise exit rates. We did say that in July, we were trending well. Delta started to peak at the end of July and really into August and the early part of September. And then we started to be encouraged by improvement in trends in the latter part of September.

Got you. I thought I could slip that by you, but I couldn't help but try.

That's all right.

And Dave, maybe coming back to on endoscopy. I think I want to start with one on just the pandemic itself. My understanding is endoscopy is slightly different versus other procedures, perhaps more outpatient ASC based, has -- what has been the impact of the pandemic on your business? Is it similar to other procedures or perhaps slightly different?

I would say, I mean, we characterize our business in kind of 3 buckets: emergent, semi-emergent and elective. A big part of our business falls into the emergent, semi-emergent space. While some like colonoscopy unfortunately falls into elective, and we're not happy with the delays in colonoscopy because the long-term impact on patient health is not good. So I think what I would say, similar to what Lauren has said is, we've been impressed by the resiliency of our customer base on a global basis. Certainly, the first wave was catastrophic. We saw delta. It was -- the impact was much less than the first wave, and we're hoping in initial signs on Omnia will be less impactful still. So the resiliency of the customer base has been very impressive to this point.

Understood. And just dwelling into the topic a little bit is Boston big in colonoscopy because, again, I almost think of Boston endoscopy as upper GI. Is that like a meaningful business for you guys in colonoscopy?

Yes. I mean we have certain device categories that are related specifically to colonoscopy biopsy forceps, snares to remove polyps, those types of things, accessories for the procedure when they find something during the examination.

We had Exact Sciences yesterday. I think, obviously, they're big in colorectal cancer screening. In their view of colonoscopy volumes are still 20% below pre-pandemic levels. I'm curious, is that a similar trend you guys are seeing? Or perhaps your view is different?

Yes. I think that's a little bit of an aggressive number. I don't see them being down to that degree. I don't know, Brian, if you want to comment on that.

I think kind of a few things. One, we definitely make devices that serve the entire GI tract, really from the esophagus, all the way through the lower GI tract. And that includes some of the basic things that Dave mentioned, snares to remove polyps or needles to inject and that kind of thing. It also includes more advanced technology to do resections on precancerous lesions and larger resections, and that includes our knives and clips to close those things. So certainly serve the entire GI tract. I would say that talking to my colleagues out there, if you're working in an inpatient setting and you're doing therapeutic endoscopy, the -- they're telling me that they're busier than ever. In fact, they feel busier than they were pre-pandemic. So I think that there was kind of a backlog and a pressure in the system that is now coming through. And I also don't think there's an appetite to delay care the way it was earlier in the pandemic. And then in colonoscopy, it's been variable for my discussions and kind of those that are in the outpatient center. Some of them are running fast and at levels similar to what they were pre-COVID, others are more impacted. I think it kind of depends on a number of factors: community, staffing, referral patterns, those kinds of things.

Understood. No, that's helpful, Dr. Dunkin. Maybe, Dave, one on labor shortage at that comes up. Does that matter for endoscopy? I don't know, to be honest, how to think about labor shortage. Is this temporal -- or is this structural for the industry?

Well, it absolutely matters. And we have seen some challenges in pockets. I wouldn't say it's ubiquitous at this point, but we've definitely seen some challenges with staff burnout, with staff that doesn't want to get vaccinated for whatever reason, different mandates and regulations wherever you go. So there's pockets where some of the customers, whether they be ASCs or inpatient facilities, have struggled with staffing. We, at this point, don't believe it's had a material impact on our ability to continue to serve the customers, and ultimately, the patients. One interesting anecdote we heard yesterday from a couple of customers that are actually going to begin EXALT-D trials as a hedge against potential staff shortages in stope cleaning and other types of support staffing.

That's a terrific point on single use. It makes a lot of sense to me. Moving up beyond COVID and near term, you guys had a fantastic Analyst Day, I think with the LRP of 68 being reiterated. I think endoscopy was interesting, right? You sized at $5 billion, I think that LRP period, which implies sort of high singles 8% to 9% If you corporate at 6% to 8% and endoscopies 8% to 9%, what are some of perhaps the key products which will drive above corporate growth for endoscopy?

Thanks for the question. It's one of the beauties of the Endoscopy businesses. We have a really strong cadence of solid launches in 2021, and we'll kind of continue that through 2022. You know we've recently had approval for EXALT Model B resolution ultra-hemostatic clip. I said at the Investor Day and we've begun deploying EXALT Model D 1.5. And then SpyGlass DS II and SpyGlass Discover continue to really grow very well and Dr. Dunkin spoke eloquently at Investor Day about AXIOS and its position in the marketplace. So really excited about that. cadence of products that would put in the marketplace in 2021. And looking forward to '22, we'll have new launches in our endoscopic ultrasound franchise, more in hemostasis and an exciting launch in the lung cancer space. So we just continue a really nice cadence of innovation that augments the natural market growth that we have.

And related question to this side, Dave, category leadership and market share gains is something that Boston talks a lot about. When you think about the LRP of 8% to 9% for the segment, what are your end markets growing? And is there a bridge to that 8% to 9% is perhaps some of the greenfield versus market share gain opportunities?

Yes. So we think that, that $5 billion market is growing at about 6%. And you mentioned the LRP of 8% to 9%. We think that's realistic. We think it's attainable. And it's a combination of organic growth in the space that we're already in, all those new product launches that I just described, some of which are augmenting existing markets, some of which are market development efforts. And then everything else we bring into the marketplace, Vijay, from clinical evidence, physician education. We have what I would call the best commercial channel in our space services and solutions to augment our product offering and really, really well thought out health economic and market access strategies. That all pulled together really helps us outpace that 6%. It was why we're confident in our 8% to 9%.

That's helpful. And when I think about that LRP, are there some variables for fiscal '22 that we need to be aware of? Should fiscal '22 be in line with LRP or perhaps some sensitivities around pandemic? How should we think about '22?

Well, we feel really good about our commitment to Boston Scientific from endoscopy for 2022. I don't know if Lauren wants to speak to a specific number, but I can tell you that our growth is diversified across multiple franchises, and I mentioned organic growth, market development and new product launches. So we feel good. And in particular, we have a strong place in endoscopic ultrasound hemostasis, single-use imaging and infection prevention. So we're confident that we put forth a number that's attainable, and we've got the strategies and tactics to go out and make that number.

And Lauren, do you want to comment on fiscal '22?

No, not at this time, Vijay.

I had to try, Lauren.

I know.

So maybe switching on to some of the products here. In EXALT B you did mention -- maybe talk about your initial launch program and some of the feedback you've gotten perhaps Dr. Dunkin, can you can comment on what perhaps some of your colleagues on the physician side or talking about EXALT B?

So Vijay, why don't -- let me give a little preamble and I'll hand it over to Dr. Dunkin, who is very much in sync with how it's being received in the field. So you'll recall, we did our first cases in July of this year. Moved into a limited market evaluation phase, and now we're in limited launch. We're super excited about the feedback and the conversions that we've had to date. We're aggressively ramping production to enable our upcoming full launch and really, really excited in the early stages of EXALT B. So I don't know, Brian, you want to talk about performance?

Yes. It's actually been really exciting to be at the bedside and see these procedures being done when the clinicians are picking up the scope for the first time. EXALT B was designed really to be optimized to be used at the bedside in the intensive care unit on these critically ill patients that need frequent bronchoscopy to clear their lungs so that they can breathe. And with that in mind, it's designed for superior suction capability, which sounds kind of mundane, but in that situation, it's absolutely critical, not only to clear in the secretions but to be efficient in clearing them. When you think about having this tube down your wind pipe while you're trying to breathe, the more efficiently you can clear those secretions and get them out, that's critical to the care of the patients. So it seems like a mundane thing to talk about suction, but it's actually the whole point of the procedure. And then the optimized visualization and just the feel of the instrument as well, some of the anecdotal comment is this feels like a real medical instrument as opposed to some of the other ones that they've tried. So it's really, really exciting to see the reception there. And I think it just accelerates this move to single-use bronchoscopes in general.

And one, you noted ramping up manufacturing conversion rates. Maybe could you provide some numbers around what is your current manufacturing capacity. And when you say conversion rate, is that a 90% hit rate everyone who's tried it is now reordering?

Yes. I mean I don't want to share specific volume manufacturing volume targets or conversion rates. I will say we're very pleased with the reception at the accounts that we've gone to. We have a very clear plan to ramp production. We've made the investments, and we're executing on that plan. And we're excited about this market. It's -- we estimate this is a served market of nearly $0.5 billion next year. So we're excited to have a really, really good product to go into an established $0.5 billion market.

Understood. And Dr. Dunkin, you mentioned something about the touch and feel, the anecdotal feedback you've received from the field. How should we think about sort of the adoption rate? Is the clinical evidence needed because post analysis you have with EXALT D, we had a clinical trial started in that space. So maybe talk about how important is clinical evidence? Or is this more for touch and feel word-of-mouth kind of product?

I think it's a little combination of both. I mean you mentioned EXALT-D, right? So that was a revolutionary technology, first of its kind in this space, very nuanced procedure. And so there was a need to demonstrate clearly that, that device was going to perform as intended for all levels of difficulty of ERCP and really in the hands of all users, not just super experts. EXALT B is a little bit of a different animal. There's already a huge presence of single-use bronchoscopy out there. The value of that is accepted. In fact, it's guided by FDA and bronchoscopy societies. We've already done bench top work doing comparative studies on the suction capability, which is really the primary factor and that will get published soon. So we will study its use in the workplace, but I don't think it's going to -- that adoption is going to pivot on some trial that really demonstrates its value. People pick it up, use it. Its value becomes obvious, and I think that's really what's going to drive the adoption.

That's a helpful perspective. I didn't even think about just an existing market versus EXALT being completely new or perhaps clinical evidence as a little bit more important. Dave, back to you on -- you mentioned $500 million market. How should we think about your market share in that existing piece and the ramp of this product rate? Is there some physician economic angle, perhaps because Boston is so large in these categories that could help drive market share for you guys?

We think the keys to driving market share are going to be product performance in this particular category. And Brian mentioned superior visualization, superior suction. We have 3 sizes so we have a range of products to meet specific clinical needs. So we think our technology, and we'll continue to iterate this scope like we've reiterated all the other scopes that are brought into the marketplace. We think that our technologies are winning and will allow us to get significant share over time.

And is that -- when I think about the longer term, should EXALT B be 20%, 30% of the market? Or have you guys given some thought on what the ultimate market share is?

We have -- I'm not going to guide specifically to that for '22 or beyond. But suffice to say, we're super excited about our opportunity and what we can accomplish in this space.

Or perhaps maybe another way to ask it would be fair to assume this should end up being a market leader in that segment, given its advantages?

Yes. Over time, potentially over time.

That's helpful. And then maybe switching on to EXALT-D, that's another product for I feel like -- I don't know if it was a [ sheet ] issue, right? We got overly excited about EXALT B and the ramp. And then it feels like we took a step back. Maybe talk about on the class point, Dr. Dunkin, on the need for clinical evidence. So you talk about your trial? I think you guys started one, where are we on the trial? When can we expect to see the data from the trial? And what do you hope to achieve with the trial, right? Should that be an inflection point for EXALT-D?

EXALT-D is, again, really revolutionary new technology, new space, new way for endoscopies to think about doing RCP. And so I think that's a different kind of adoption curve than maybe what we'll see with EXALT B, and certainly, with some of the other technologies that we bring. In fact, I would liken it to what we've seen in some of the other divisions, say, urology and with a single-use ureteroscope with LithoVue. And there's a process. So first, the endoscopy community has to understand the problem. I actually think we're there at this point. They need to then understand where the technology fits into addressing the problem and on which patients and then expand from there, basically. And that's exactly what we've seen with LithoVue. We saw that with SpyGlass in the ERCP space. we basically created, if you will, or at least maybe that's a little bit of a strong word, but we certainly -- yes, we certainly democratize the ability to do direct visualization into the bile duct and into the pancreas duct. It wasn't that had never been done before, but it just wasn't a practical thing to do. So I think you're going to see a similar kind of adoption curve for EXALT-D. Now we've sponsored 4 studies. 3 of them are complete and already in publication and they're out there in the peer-reviewed literature. One was a bench top study that compared its function in a simulation model to other reusable technology. And then 2 were clinical trials. One before we even had FDA clearance, and we did that to really assure that this thing was going to perform as it needed to, even though that wasn't required by any regulatory body in order to get the clearance. We did a larger trial post launch in order to show that it could be used for all levels of difficulty and to begin to get a view across different levels of expertise in users. So that was our third trial. And then the fourth, which is ongoing right now, has an upper limit of up to 1,000 patients targeted as more centers worldwide view, more users. And again, all of those levels of difficulties to really assure that it can be used in any RCP that you want to apply it to. So those are the studies that we've done. There is a study out of Florida from Bang et al, which is really interesting, where they did a prospective comparison between EXALT-D. -- well, it's prospectively collected data and then they looked at it retrospectively when it's between EXALT-D and their reusable scope. Again, demonstrated that it performed as well, could be done on all types of ERCP. They actually liked it as far as its ability to help guide cannulation. So there's actually quite a bit in the literature now around its utility. What's exciting is we're now starting to see some publications and 1 just came out from Indiana University, a hugely experienced group of endoscopists there talking about which patients do use a single-use technology on for an ERCP space. And that's a piece that I think has been missing and is going to be super helpful to the endoscopy community. So patients that have an active infection, particularly from a multidrug-resistant organism, you don't want to spread that to another patient and you don't want to infect your fleet of reusable scopes in patients that are particularly vulnerable to having an infection, think about immunocompromised or immunosuppressed. These are the things that the endoscopy community is starting to identify to say, look, this is a patient population where you should be picking this up off the shelf.

That's helpful comments. Dr. Dunkin. Maybe on that point of we now have a defined clinical use case. Immunocompromised, I mean, that makes total sense with lower infections. But I think physician economics is something that's come up, right, when you look at reusable scopes. And I think you have a competitor out from Europe who's spoken about different price points. Maybe, Dave, this is more for you. When you think about the reimbursement landscape, do you feel like the product is priced appropriately. And given that patient segment of immunocompromised or perhaps the clinical use case is more clear. Does that change your view on your TAM? I think the prior TAM was like $1 billion that was put out?

Yes, let me address your second question first, and I'll go back to our ASP. It's interesting and it's a fair question. And I reflect on LithoVue maybe as a good corollary. I was actually running the urology business when we launched LithoVue, and we had kind of a similar start. And then as the adoption -- as we identified lower pole stones in the kidney as the perfect application for the use of LithoVue, we started to see more and more adoption. And with more and more adoption for that particular application, the use within labs expanded and expanded again and expanded again because customers and staff got facile with using the technology. And so the hypothesis will be as, some of the use cases that Dr. Dunkin just explained, get labs and staff comfortable with the use of EXALT-D that it will be used more broadly than that particular -- those particular applications. As it relates to reimbursement, we talked about, as of October 1, all Medicaid patients are covered. That's about 40% of the ERCPs done in the U.S. And we've seen anecdotally some very encouraging private pay coverage for the device as well. So we feel like the reimbursement situation, in the U.S. particularly, is in a good spot. And we're excited and we're sharing that message with our from our selling team, from our health economics team, with physician customers, GI staff customers and accounting customers within the hospitals that we're calling on. As it relates to our ASP, I think similar to the comment I made about the bronchoscope, we feel like in this category, the product performance wins. In that ASP. It's not irrelevant, but it's less relevant than the ability of the scope to get you where you need to be and allow you to perform that ERCP. And we're very confident in the technology that we have in the marketplace. We're already in version 1.5. We have additional iterations in the pipeline, and we're confident that we know these customers, we know these procedures and that will have the right product for them in this category.

I would say -- Vijay, sorry, just to add a couple of things. This extension of your inventory is an important one. And Dave mentioned an anecdote about some places considering the use of a single use to adenoscope because of the burden of staffing to reprocess the reusable stuff. Over 130 manual steps. You need to train persons to do that. And we've got centers, high-volume sophisticated centers with a lot of inventory on hand that, by the second half of the week, they're going to single-use scopes because they have no more usable inventory on hand. So I think as people get more and more comfortable to technology, as Dave mentioned, they'll just see that as a natural extension. Or if I'm in a medium to smaller unit, I'm not going to want the infrastructure that's required and the monitoring that's required in order to make sure that their reusable duodenoscope is patient-ready. And so that's another factor that I think people as they get more comfortable with the scope, those barriers to adoption will drop. The other thing I would say is that, as far as the kind of health economics analysis, our team has really worked with some KOLs and key opinion leaders in this. I think there's some really nice publications, much more sophisticated modeling taking into account the pass-through payments that will make that argument strongly that when you compare the use of a single-use duodenoscope to a reusable with other reprocessing methods, that there's great value there.

That's helpful perspective, Dr. Dunkin. Any sort of thoughts, given where we are in the product cycle, how should we think about EXALT-D revenue ramp over the LRP period?

Yes. So we're growing month-over-month, quarter-over-quarter, adding new accounts, seeing strong reordering rates. And we plan to continue that, obviously, through '22 and beyond. So again, we still believe in this technology, we still believe that there is a place in the market for it. And we believe that we have the right product, and we'll continue to make enhancements to that product to be the leader as the space evolves and develops.

Understood. And then another thing, at your Analyst Day there, which came up with AXIOS -- again, these are products were at least from my perspective, I haven't spent a whole lot of time on. And some of these numbers are big. I think you sized your current market at $0.5 billion. Will you think there's an expanded market opportunity of rounded like $2 billion number, right? That's a big number. Maybe talk about this market. When you say GI structures and out obstruction rate, how big of a deal is this? And what is the current standard of care? Like why is AXIOS a game changer in this market?

Yes. I'm actually going to just say that AXIOS is one of the most exciting products that we have in our it is absolutely differentiated in the marketplace. It allows us to expand our category leadership because it's unique in the space. I would defer to Dr. Dunkin, who is much more eloquent on why it is as good as it is and what potentially it can offer in some of these other markets that we've identified and will ultimately try to enter.

Yes, I would say we were talking a little bit off camera earlier about my background as a surgeon and as a therapeutic endoscopist, and so it's kind of have a unique perspective on both of those worlds. And one of the reasons why I joined this company and certainly a reason why I've been a long time consultant of Boston Scientific is, if you look in the surgical space, the natural move is away from kind of transabdominal or transthoracic into an intraluminal space. And I don't think there's a better company around to embrace that paradigm. And I've certainly seen that paradigm change my surgical practice through 25 years of practice. And it's not just GI, you see it in cardiovascular and neurosurgery and all those things. AXIOS is a prime example of that. So AXIOS is really a surgical tool delivered endoscopically. It's a way to connect one part of the body to another. And it's completely changed how we manage some really serious disease states like severe pancreatitis that lead to infection and fluid collections and that kind of thing. But when you think about it that way, like I can now endoscopically connect your stomach or your intestine to something else in your body and do that in a completely noninvasive way. That's when you get excited about expanding this. And so you mentioned some potential ways to do that. One is an outlet obstruction from the stomach. For whatever reason where the stomach can't drain properly, the current state of the art for that now is either to do surgery and bypass the stomach, connect it to the intestine downstream, or to place a stent to cross that area of blockage. Both of those have limitations that AXIOS has the potential to overcome. And in fact, these -- AXIOS is being used to bypass that blockage, connect the stomach downstream now on an off-label basis in many places around the world. And it seems to offer the potential for better drainage of the stomach and less long-term inclusion that you might see in the stent. So that's exciting. It's also exciting to see the clinical community kind of lead with that. And we're certainly doing the homework and the clinical evidence that's required to make sure that, that's done safely, well and that the entire inducement community can adopt. And that's not just for that scenario. That is for connecting the gall bladder and draining that internally. And even in the metabolic space. We know from the surgical world and gastric bypass that bypassing the kind of the most -- the early part of the intestine, if you will, has a positive metabolic effect for diabetes, for fatty liver disease, helping to control those diseases. It's exciting to work through the opportunity to, hey, can we do that endoscopically using AXIOS. And we're certainly working down that pathway as well.

That's helpful perspective. And it totally makes sense, right? I think a big part of robotic surgery has been minimally invasive. And this is an extension of -- my understanding is, right, cut open versus doing end alone makes total sense to me. I probably should have spent more time on AXIOS since just spending time on EXALT-D now. Maybe one last question on -- you've noted Dr. Dunkin that the clinical community is leading this and using off label. I mean for me, those are things which are -- it's a really, really positive sign, right? So do you need for the clinical evidence? Or do you need an FDA label to accelerate the trend? Or how do you see the market evolving?

I think it's useful. I mentioned AXIOS for draining the gall bladder. There are some instances where you just can't do surgery to manage a sick gall bladder and draining it internally is, we believe, is a superior method to doing that externally. We actually have that as an indication in Europe for the use of AXIOS. We want to get that as an indication within the U.S. We are in a trial to do that, which is very mature in that trial. So hopefully, we'll get those results out soon. But I think, yes, I think it's helpful. I think it helps to clarify to the endoscopy community exactly which patients, what's the technique, what should I expect for the performance. But you're right. I mean when the clinical community is leading you, that's always a good sign of the need.

Got you. Understood. And then maybe, Dave, you did bring up SpyGlass that's how the market has evolved. What is -- again, there are so many products within that space, right? Sometimes it's hard for us. Investors like to gravitate towards, oh, it's WATCHMAN, it's X amount of dollars rates of maybe perhaps how big is SpyGlass for you guys? What is the current penetration of that product how many years of runway do you have SpyGlass. Because I feel like every quarterly earnings call, certainly, the team speaks about SpyGlass. It comes up a lot in conversations. But we don't know a whole lot about SpyGlass to be honest.

Yes. So SpyGlass is a great example of a market that we've developed and that we continue to have massive opportunity in. Right now, we have SpyGlass DS II which is the fourth iteration of SpyGlass and over the past, I think, 12 years. In every time we add capability to our SpyGlass platform, the adoption increases. So we continue to believe that the runway is significant. We're going to see strong double-digit growth again next year on top of the double-digit growth that we're seeing this year. We're also really excited about SpyGlass Discover, which is a shorter version of SpyGlass, which is opening up new opportunities for interventional radiology as well as surgeons to treat patients with liver and gallbladder disease that they didn't have before. Early adoption of that has been a really exciting. So adding just another log to the SpyGlass fire, if you will. And in addition to that, we continue to develop small scale devices to use through the SpyGlass working channel so that when you're in there looking, you can go in and get diagnostics, and in some cases, intervene on the problem at hand. So it's a franchise that it's kind of a mini endoscopy, right? We start with SpyGlass, we start to iterate with wires and baskets and other types of devices to intervene with and you build out a broad portfolio and the market continues to grow. So I think we're in 4,500 accounts globally with a lot of headroom above that.

That's helpful. Sorry, go ahead, Dr. Dunkin.

Well, just to add -- to highlight a bit, particularly around SpyGlass Discover. Because SpyGlass is essentially a mini endoscope that you can essentially drive up the bile duct or the pancreas duct and look up into those structures. And it's revolutionized how gastroneurologists have done ERCP bringing that technology. And putting it into the hands of surgeons so that they can have the same capability, but to do that surgically and then doing it with interventional radiologists so that they can do it via a percutaneous approach, that's really revolutionizing how they're doing their work as well. So it's a really exciting example. When you think about an interventional radiologist who is used to looking at shadows and 2-dimensional images on a screen now has a full color image of the inside of a bile duct that they can access percutaneously. It's changing how they work. And it's actually one of the most exciting things they're talking about at their meetings. So it's an example of leveraging the technology that we have such a strong basin, fourth generation and then empowering everybody that touches the bile duct to have that kind of technology in order to treat patients. That's what gives you that continued adoption by additional specialists.

That's helpful perspective. Perhaps the radiologists now need to go a new training, right, from black and white to color imaging.

They actually have to. And I have to tell you 1 of my responsibilities in the organization is professional education. And we have a very sophisticated training program for both surgeons and interventional radiologists on how to do cholangioscopy. And you're right, like it's an eye-opening experience for interventional radiologist, and they're loving it.

Fantastic. And maybe in the last couple of minutes here, Dave. I think the corporate -- the goal is 50 basis points of margin expansion annually when you think about endoscopy. Is endoscopy margin expansion in line with corporate? Or is that about or below and talk about any perhaps near-term impact from supply chain?

Yes, great question. I think I would say every business unit in this company right now is laser focused on margin, including endoscopy. We're accretive from a margin standpoint to Boston Scientific, but we're not resting on our laurels. We are absolutely laser-focused on improving it. We have very specific goals. We think they're achievable, and we will go out and make that number. As it relates to supply chain and disruptions, I can't be more proud and thankful to our global operations team for the work that they've done to continue to supply not only the Endoscopy business, but the broader BSC with products so that we can meet our customers' needs and have their patients be treated. But it's precarious like you read in the Wall Street Journal every day. But I feel good about our team and good about where we are relative to supply chain and the plans that we have to continue to meet the customer demand.

Got you. And then maybe a last one on my side. I know Boston Scientific put out ESG targets metrics. How does that apply to you and your team, Dave, do you have any ESG metrics as being part of comp metrics? Or do you track that at a divisional level?

Yes, I'm glad you asked that question because we're really proud of our ESG commitments and actually an executive sponsor for our ESG efforts at Boston Scientific, I would say that we have the corporate ones that you're probably aware of our free up goals around women in management, around increasing multicultural representation and making sure that we're recognized as a leader in our workplace inclusion. And we're tracking very well towards those. I can speak for Boston Scientific endoscopy division, we have a diversity equity and inclusion council that has 4 key pillars. And I feel really good about the progress we're making in each of these. And I'm proud of the team. It's largely voluntary participation from team members in addition to their current roles. And they embrace it, and they love it, and it's a great way for them to give back and to participate in making Boston Scientific the best company in the space.

Fantastic. I think with that, we're at the end of time. Dave, Dr. Dunkin and Lauren, thank you so much for spending the time this morning.

Great. Thank you, Vijay.

Thank you.