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Intrinsic Value is all-important and is the only logical way to evaluate the relative attractiveness of investments and businesses.
Intrinsic Value is all-important and is the only logical way to evaluate the relative attractiveness of investments and businesses.
Welcome, ladies and gentlemen, to the Second Quarter of Fiscal Year 2023 Earnings Conference Call for Tactile Medical. [Operator Instructions] Please note that this conference call is being recorded and will be available on the company's website for replay shortly.
Before we begin, I would like to remind everyone that our remarks and responses to your questions today may contain forward-looking statements that are based on the current expectations of management and involve inherent risks and uncertainties which could cause actual results to differ materially from those indicated, including those identified in the Risk Factors section of our annual report on Form 10-K as well as our most recent 10-Q filing to be filed with the Securities and Exchange Commission. Such factors may be updated from time to time in our filings with the SEC which are available on our website. We undertake no obligation to publicly update or revise our forward-looking statements as a result of new information, future events or otherwise. This call will also include references to certain financial measures that are not calculated in accordance with generally accepted accounting principles, or GAAP. We generally refer to these as non-GAAP financial measures. Reconciliations of those non-GAAP financial measures to the most comparable measures calculated and presented in accordance with GAAP are available in the earnings press release on the Investor Relations portion of our website.
I would now like to turn the call over to Mr. Dan Reuvers, Tactile Medical's President and Chief Executive Officer. Please go ahead, sir.
Thanks, operator and welcome, everyone, to our second quarter earnings call. I'm joined on today's call by Elaine Birkemeyer, our Chief Financial Officer. Let me provide a quick agenda for the call. I'll start with a high-level overview of our financial results, along with the discussion of the key drivers of our sales performance in the second quarter. Then I'll share the progress we've made in recent months from an operational standpoint with a focus on some of our most notable accomplishments. Elaine will review our second quarter financial results in greater detail as well as our latest 2023 financial guidance which we increased in today's press release. And finally, I'll provide some concluding thoughts on our outlook and key areas of focus for the remainder of the year before we open the call for questions.
Now let's begin with a review of our financial performance. I'm really pleased with our team's ability to deliver another quarter of performance that exceeded expectations, including double-digit revenue growth, operating leverage that led to improved profitability, strong cash flow generation and enhancements to our balance sheet. In the second quarter, we achieved total revenue growth of 15% year-over-year to $68.3 million. Our total revenue performance exceeded our expectations driven by stronger-than-anticipated contributions from our lymphedema product.
Looking at our performance by product line, Lymphedema revenues increased 16% year-over-year to $60 million, while our Airway Clearance revenues increased 4% year-over-year to $8.3 million. We complemented our sales performance with strong year-over-year improvements in our operating results during the second quarter, including a $6.1 million improvement in our GAAP operating income, year-over-year reductions in our GAAP and non-GAAP net loss of $4.5 million and $4 million, respectively and a $4.4 million improvement in our adjusted EBITDA. This strong financial performance across the board enabled us to generate $13.9 million of cash flow from operations, a quarterly record in our 7-year history as a public company.
Turning to a more detailed discussion of our sales performance in the second quarter. In our lymphedema product line, our stronger-than-anticipated performance was largely a reflection of the engagement, retention and improving productivity that we saw across our sales team. From a retention perspective, we ended the second quarter with 249 field sales representatives compared to 250 at the end of the first quarter and the beginning of 2023. Our improved sales force productivity benefited from a combination of factors, including the increasing tenure of our team, the introduction of new products and our continued efforts to improve our operational efficiency. Most notably, in March, we began the full market release of Entre Plus, our next-generation Entre system which we offer for patients who qualify for a basic pneumatic compression device.
As a reminder, many payers require patients to begin with a basic pump as a prerequisite before considering whether their condition qualifies them for an advanced system like the Flexitouch. With this in mind, the development and introduction of our Entre Plus system reflects our increased focus on identifying, engaging with and supporting this important segment of lymphedema patients.
In connection with the full market release of Entre Plus, our team engaged with existing and prospective prescribers to introduce the new system and its features and then work with them to identify qualified patients who could benefit from its use. The response to Entre Plus by both prescribers and patients has been very favorable so far and we've seen strong adoption and sales growth in this portion of the market during the initial months post launch.
As a reminder, both our Entre Plus system and the Flexitouch ComfortEase garments that we launched last year feature enhancements to facilitate the bilateral treatment of lymphedema in the lower extremities, a common therapeutic area of focus for patients suffering with lymphedema related to vascular disease. With these 2 enhanced treatment options in our portfolio, we continue to see strong growth in sales to patients treated at vascular clinics.
In addition to the strong market response to our Entre Plus system, the productivity of our sales team continued to benefit from our efforts to improve our operational efficiency by streamlining medical record exchanges and reducing the administrative burden on both our reps and prescribers. In recent quarters, we've begun to make progress in our efforts to reduce the time allocated by our sales reps to processes that limit their market development bandwidth, including obtaining documentation and conducting in-home patient demos.
We've also continued to improve the efficiency of our interactions with prescribing clinicians with simplified forms and an enhanced process for exchanging documents. And as I discussed on our earnings call in May, we introduced a more streamlined internal process for the submission of claims data for patients covered under Medicare which, along with CMS' discontinuation of its requirement for a certificate of medical necessity at the beginning of this year, helped reduce the administrative burden for clinicians.
With respect to our Airway Clearance product line, the more modest sales growth we saw in the second quarter was the result of 1 large DME partner experiencing slowed AffloVest placements. This was due to the eligibility criteria changes associated with the expiration of the COVID-19 public health emergency waiver on May 11. The return to prepublic health emergency eligibility requirements slowed their processing and placements of AffloVest.
As a result, we now expect this DME partner's volume to be lower and we've adjusted our guidance accordingly. With that said, it's worth noting that the remainder of our DME partners continued to grow in the second quarter.
Turning to an update on our operational performance. In recent months, we've continued to execute across multiple aspects of our strategy to further enhance our positioning in the markets we serve. Among our accomplishments, we continue to advance our product portfolio with multiple patient-centric innovations, educate patients and clinicians, enrich our senior leadership team with the addition of key talent and increase our available borrowing capacity to support our future growth initiatives and enhance the company's financial flexibility.
With this as a backdrop, I'll walk through a few of these items in further detail, beginning with an update on our new product initiatives. As I touched on earlier, we've been very pleased by the reception of our Entre Plus system has had -- it's been well received from clinicians, patients and our sales team since its full market release in March. Entre Plus is the first generational update to our Entre system since we introduced it 8 years ago. It's been redesigned to include a variety of enhancements over the prior generation with the goal of improving the overall patient experience while delivering the same therapeutic benefits.
Among its enhancements, Entre Plus features an LCD-based user interface that provides patients with easier access to information about their treatment session. It also features active garment deflation so that the patient can more easily remove and store the system after they complete their treatment.
For those patients that require bilateral treatment, the system's controller was designed to allow them to treat both of their limbs simultaneously, an important part of achieving efficient treatment. And importantly, for those patients who may later require a more advanced pneumatic compression device for their therapy, our Entre Plus was designed with consistency across our product family. So patients' migration to Flexitouch, if necessary, becomes more seamless.
Based on the feedback we've received during the initial months following our launch as well as our strong lymphedema sales performance in the second quarter, we believe these primary features and enhancements are resonating with customers. During the second quarter, we also continued to expand the capabilities of our Kylee mobile application. The latest version of the Kylee app includes enhanced features that enable patients to easily record, track and compare changes in their skin condition, limb measurements and other lymphedema-related symptoms. We believe these additional enhancements continue to boost Kylee's utility as a resource for patients to monitor their disease progression and treatment progress and then share this information with their physician.
Kylee also now includes improved treatment reminders, making it easier for patients to establish a routine of consistent self-treatment and facilitating adherence to therapy. Based on the feedback we obtained during the quarter, these new enhancements and the benefits they bring to patient reporting and adherence are both recognized and appreciated by the clinicians we serve. And from a patient perspective, we're continuing to see compelling adoption and utilization trends in the second quarter with strong sequential growth in the number of downloads and user check-ins. There were approximately 500 unique customer downloads of Kylee in the second quarter, a 37% increase over the first quarter and the number of patient check-ins on Kylee grew to nearly 63,000 in the second quarter.
Overall, in the first year following the launch of the Kylee app, we've been very pleased with the progress made from our product development, adoption and utilization standpoint. We look forward to enriching Kylee's utility and establishing it as an instrumental resource for the education, diagnosis, training and effective treatment of lymphedema.
In addition to this progress, we were pleased to complete the prelaunch stages for our ComfortEase upper extremity garments during the second quarter and initiated our full market release in July. Like our lower extremity ComfortEase garments which we launched last summer, the design of these upper extremity garments drew on our team's experience in the design of athletic apparel with the overreaching goal of improving the treatment experience for our patients. Our ComfortEase garments are comprised of materials that are lighter, cooler and more maleable than our prior garment offerings and they were designed with extensive input from patients and therapists to make them easier to put on and take off, facilitating the initial patient training and daily treatment process.
Our new chest garments also provide improved therapy to the axillary region, an important part of achieving optimal therapy among breast cancer survivors. As our pace of progress this past quarter illustrates, we remain committed to a strong cadence of new product innovation with enhancements focused on addressing the lifestyle needs of our patients, improving the digital functionality of our products and optimizing the treatment process.
Shifting to a discussion of our efforts to raise awareness and educate the market on the underserved conditions we address, in addition to the progress made in educating patients with our Kylee app, we hosted a total of 41 clinician-focused education programs during the second quarter which saw participation from approximately 1,200 clinician attendees. These events covered a variety of important subjects, ranging from introductory programs on the causes, diagnosis and treatment modalities of lymphedema broadly as well as programs focused on specific manifestations such as lymphedema related to breast cancer and lipedema. Many of our programs also enabled our clinician attendees to earn continuing education credits for their participation.
With respect to our airway clearance product line, we sponsored an article published in the June edition of RT Magazine, an industry publication focused on respiratory care. The article summarized the results of a blinded, randomized patient preference study comparing 4 high-frequency chest wall oscillation devices on the market, including our AffloVest. The study was conducted by an independent market research firm and consisted of 30 symptomatic adults, all naive to vest therapy. Each participant in the study trialed all 4 devices at equivalent settings for 15 minutes each with the manufacturer's instructions for use to guide them and a respiratory therapist on hand to ensure proper fit.
During each treatment, patients were assessed with a standardized questionnaire that evaluated patient preference across several key categories. Most notably, 93% of the participants stated they favored the AffloVest over the other devices they trialed and reported a greater likelihood of compliance to the therapy if it was the device they were prescribed. Specifically, 90% of participants stated they believed they would be compliant with the daily AffloVest therapy.
In addition, the researchers found that 77% of the participants preferred AffloVest controls and features. 70% preferred its overall fit and 90% preferred the experience of removing the AffloVest in comparison to the other devices they trialed. The results of this study support the conclusion that AffloVest's features, including the fact that it's completely portable, comfortable to wear and quiet while in operation, are likely to increase patient compliance. It also adds to the existing body of evidence that the DME reps we partner with can utilize in their discussions with potential prescribers and patients.
While most of our growth has come from the expanding universe of eligible patients, we believe this paper can equip our DME channels to compete more vigorously for competitive share as well. And lastly, we added to our senior leadership team. In June, Dr. Tony Gasperis as the company's Chief Medical Officer was appointed following the retirement of Dr. Thomas O'Donnell. Dr. Gasperis previously served as the Chair of our Scientific Advisory Board since 2020. He's a Professor of Surgery and Director of the Center for Vein Care at Stony Brook University as well as the past President of the American Venous Forum. Dr. Gasperis is an experienced health care leader and enthusiastic educator, dedicated to delivering innovative care and unique approaches to building awareness of lymphedema.
And in July, we appointed Sherri Ferstler as our Senior Vice President of Sales, succeeding Eric Pauls. Sherri joins Tactile Medical from Johnson & Johnson Vision, where she led a team of 325 sales-related personnel as VP of Sales for North America. In the course of her more than 25-year career in health care, she's also led national and regional sales teams at Bayer Diabetes Care, Endo Pharmaceuticals and Mylan Pharmaceuticals.
Sherri has a successful track record of developing sales teams and delivering growth in revenue and profitability. We're excited to have Sherri join Tactile Medical, adding additional depth to the richly talented team that we've assembled.
Elaine will now review our second quarter financial results in more detail, along with our financial guidance for 2023 which we updated in today's earnings release. Elaine?
Thanks, Dan. Turning to review our financial results. Unless noted otherwise, all references to second quarter financial results are on a GAAP and year-over-year basis. Total revenue in the second quarter increased $8.7 million or 14.6% to $68.3 million. By product line, sales and rentals of lymphedema products which includes our Flexitouch and Entre systems, increased $8.4 million or 16.2% to $60 million and sales of our airway clearance products which includes our AffloVest system, increased $329,000 or 4.1% to $8.3 million.
Continuing down the P&L. Gross margin was 70.7% of revenue compared to 72.5%. Non-GAAP gross margin which excludes noncash intangible amortization in both periods, was 71.1% compared to 73%. GAAP and non-GAAP gross margins in the second quarter of 2023 were impacted by higher labor rates and material costs as well as higher costs related to new product launches and changes in our mix related to strong growth in sales of our Entre Plus system.
Second quarter operating expenses decreased $1.1 million or 2.3% to $46.2 million. The decrease in GAAP operating expenses was driven primarily by a $600,000 decrease in sales and marketing expenses and a $500,000 decrease in noncash intangible asset amortization and earnout expense.
Operating income was $2.1 million compared to an operating loss of $4.1 million. The $6.1 million improvement in our operating income was driven by a $5.1 million or 12% increase in our gross profit as well as the aforementioned $1.1 million or 2% decrease in our operating expenses. Non-GAAP operating income was $3.6 million compared to an operating loss of $1.8 million. As a reminder, our non-GAAP operating income excludes noncash intangible amortization and earnout expenses as well as certain nonrecurring operating expenses in the prior year period. We've provided a detailed GAAP to non-GAAP reconciliation in our earnings press release.
Other expense net was $800,000 compared to $600,000 last year, primarily due to an increase in interest expense, driven by a higher average interest rate on outstanding borrowings compared to the prior year period. Income tax expense was $1.3 million compared to a benefit of $20,000 in the second quarter of 2022. Net loss declined $4.5 million year-over-year to $100,000 or $0.00 per diluted share. Non-GAAP net income increased $4 million to $1 million compared to non-GAAP net loss of $2.9 million last year.
Adjusted EBITDA increased $4.4 million to $6.1 million or 8.9% of sales compared to $1.7 million or 2.8% of sales last year.
Turning to the balance sheet. As of quarter end, we had $63.2 million in cash and $47.5 million of outstanding borrowings. This compares to $21.9 million in cash and $49 million of outstanding borrowings as of December 31, 2022. The increase in cash was driven by the reduction in net loss and improvements in working capital efficiency compared to prior year quarter and prior periods.
Specifically, working capital was a source of nearly $10 million of cash in the second quarter of 2023 compared to $1.5 million last year and a use of $2.9 million in the prior quarter. This significant improvement in working capital efficiency to date has been driven primarily by better days sales outstanding performance which has resulted in strong cash flow from operations. The $13.9 million of cash flow from operations we generated in Q2 is a quarterly record for the company which is not only impressive but also underscores our confidence in our ability to deliver a cumulative free cash flow target of more than $75 million for the 3 fiscal years ending 2025.
We made additional strides to further strengthen our balance sheet, adding to our financial flexibility we entered into an agreement to our existing credit agreement that extends the maturity of our term loan and the revolving credit from September 8, 2024 to August 1, 2026. It also expands our availability -- available borrowing capacity to $55 million which is an increase of $8.25 million. And lastly, our amendment agreement includes more favorable borrowing terms, including lower rates and less restrictive covenants.
Shifting to a review of our 2023 outlook which we updated in today's press release. We now expect full year 2023 total revenue of approximately $274 million to $278 million, representing year-over-year growth of 11% to 13% compared to our prior guidance of 10% to 11.5%.
Our total 2023 revenue guidance range now assumes sales and rentals of our lymphedema products increase approximately 13% to 14% compared to our prior guidance of 9% to 10% and sales of our airway clearance products increase approximately 0% to 5% versus our prior guidance range of 18% to 21%. These updated growth assumptions reflect better-than-expected sales of our lymphedema products in the second quarter and higher growth expectations in the second half of 2023. It also assumes updated expectations for airway clearance products in 2023.
For modeling purposes, for the full year 2023, we expect our GAAP gross margins to be approximately 71%, our GAAP operating expenses to be flat to down 1% year-over-year compared to our prior expectation of low single-digit increase year-over-year, interest expense of approximately $3.8 million, a GAAP tax rate of 57% compared to our prior guidance of 61% and a fully diluted weighted average share count of approximately 23.5 million shares.
Based on the stronger-than-expected profitability performance in Q2 and our updated expectations for the second half of 2023, we now expect to generate adjusted EBITDA of approximately $25 million to $27 million in 2023 versus our prior guidance range of approximately $23.5 million to $25.5 million. Our adjusted EBITDA expectation assumes certain noncash items, including stock compensation expense of approximately $9.8 million compared to $11 million previously, intangible amortization and changes in fair value of contingent consideration of approximately $5.8 million and depreciation expense of approximately $2.5 million, both of which are unchanged versus prior guidance assumptions.
With that, I'll turn the call back to Dan for closing remarks.
Thanks, Elaine. With another quarter of strong financial and operational performance under our belt as well as a recently enhanced balance sheet, we believe we're incrementally better positioned to pursue our growth and value creation objectives going forward. In the second half of this year, we remain committed to delivering further execution with respect to our 4 strategic priorities which as a reminder, are as follows: improving the productivity of our lymphedema field sales team, expanding airway clearance therapy through our DME providers, introducing new products and innovations focused on addressing the lifestyle needs of our patients and improving digital functionality and therapy optimization; and finally, enhancing our operational efficiency to continue to reduce our overall cost to serve while staying focused on patient satisfaction.
We're pleased to have been able to impact so many patient lives as we demonstrate improving profitability, strong cash flow generation and an enhanced balance sheet in addition to our return to double-digit top line growth. We look forward to continuing our recent momentum towards achieving our stated longer-term, strategic and financial goals in 2023 in the coming years.
I'd like to close by thanking our team members for their impressive contributions to our development and growth as an organization this past quarter, thanks to our customers, suppliers and shareholders as well for their continued support. And with that, operator, we'll now open the line for questions.
[Operator Instructions] And our first question will come from Adam Maeder with Piper Sandler.
This is Simran on for Adam. I want to start off with 1 on the sales force and specifically the transition at the SBP rule. Just any details or color that you can provide on that transition? Is there a change to the company's strategy regarding sales force? And what disruption, if any, could this signal for the sales force looking ahead?
Yes. Good question. First of all, this is not an indicator of any change in strategy. This is just a change in people that are basically running our play. Eric did a nice job for us, of course. But he and I had a good open dialogue about a transition that was in store. And I think that it led to a really good, smooth succession transition. We had luxury because of some good communication to ensure a competitive search and was really, really pleased to be able to land the kind of talent that I think Sherri is going to bring to the company. She's brought VP level experience. She's got more than 2 decades of senior level leadership. And interestingly, she had an associate rep model that looked a fair amount like ours, bringing in young salespeople and focusing on people development. And she was able to demonstrate some of the best retention results at J&J. So I think all of those certainly position her nicely.
I think the other one I would just point out is that we are really lucky to have a really strong next-level leadership team. Our 4 area directors on the lymphedema side have all been with us for a number of years and 3 of them of the 4 have been with us for over 8 years each with the company. I think they have 30 years collectively among the 4 of them with us. So I think that if you're a salesperson, you're a regional manager is still the same person, your area director one notch up is still the same person. And our strategy is still the same. So I feel like we're going to be able to step across these rocks quite smoothly.
Okay, perfect. I appreciate it. And just for my follow-up, on AffloVest, I guess, we were pretty surprised to see it was down sequentially as well. Maybe walk us through the impact of the eligibility criteria changing and why it was isolated to only that one DME supplier. And then, I guess, the updated guidance implies a pretty significant deceleration in the second half. So maybe any additional puts and takes for the second half of the year.
Sure. I think the first one, just to point out to the obvious is when you're going through a DME and not your own direct sales force, life gets a little bit lumpier. We did have one large DME that had really adopted the PHE criteria and implemented it more so than the balance of the field. And when I say PHE, just to be clear, public health emergency. So when COVID was established, there were about -- there was about a 3-year period where CMS said that there was -- they were going to relax some of the criteria. And for this specific category, it was affected. And one of the most specific ones is you didn't need a CT scan to submit or get approved for this. It expired in May, early May, after 3 years of being in place. And this DME, I think, had taken advantage of that relaxed criteria a bit more. So they're pivoting back to the original criteria. And I think we expect that we'll probably see a little bit of slowed placements with them as a result.
I think the important balance is we have seen growth from all of the top -- other top 10 within our list of DME customers. And I think that it's largely because they've maintained the original criteria all the way through. I didn't necessarily want to retrain their reps or their HCPs. So that's a little bit of background on it. I think we were certainly fortunate, as I said, at the same time to see such strength in our lymphedema business which was more than offsetting and we expect that to continue through the balance of the year as well.
Next question comes from the line of Margaret Kaczor with William Blair.
I wanted to start out with lymphedema, obviously doing quite well, nice meaningful increase in guidance. How much of that is on Entre Plus, I guess? And what is implied of Entre Plus not only this quarter, Q2 but also going forward? The real question, I guess, behind all of this is any details, I guess, over percentage of Flexitouch accounts that tried or purchased Entre Plus and your sense of market share on the back end of that launch and has it increased?
Margaret, it's Elaine. I'll start and I'll ask Dan to fill in here. But -- so for the quarter, we saw growth in both our basic and advanced pumps, the Entre and Flexitouch. We did see faster Entre growth. And again, this -- we really walked into this quarter with the new product with a focus across both products. The basic pump category is an important one for us. Many payers require a basic pump trial first before moving to a more advanced pump if the patient's condition warrants it. So it's an important area for us to be in. So we saw, I think, the reception of our Entre Plus product that was very favorable with our patients and our physicians help drive that strength as well as just kind of that balanced focus across the entire kind of portfolio there. We do expect to see those trends as we move into the back half of the year. And I think that's what having strength in both of those products is what helped led us to taking up our guidance for the lymphedema product in the back half of the year for the full year, too.
Yes. And I would just add too, Margaret, that I think to your question about share, we don't have specifics but I think that given the kind of strength we've seen in our Entre Plus, we certainly would expect that we picked up a bit of share here recently. I think it also positions us well with our patient base. So those that become eligible for Flexitouch, we've established that relationship. We've started to provide the basic therapy available to them. And hopefully, with the continued expansion of Kylee, continue to maintain that relationship with those patients through their journey.
Okay. I appreciate that. And then on the AffloVest side, I'll maybe push a little bit more specifically on that. Seems like second half growth for AffloVest maybe is in the low single digits despite having an easier comp in fourth quarter of '22. So I'm just curious, how do you look at recovery within that business? And as you look at growth drivers, are you just not penetrating a lot of the HME accounts so you could go deeper that way where you're kind of broadening out your breadth? Or do you expect this one DME to come back eventually with good growth?
Yes. I think that we certainly expect, I think, this one to come back. I think that they've sort of reestablished a new baseline. That's the headwind that we'll be overcoming. We have continued to grow, as I said, in all of the others in the top 10 and expect to continue to do that. But there's a little bit of a put and take there. I think to your question about what are we doing to continue to invest in the growth, first of all, the study, I think, is an important one. As I've said many times, I think most of our understanding of the units that have been placed by our DME partners have largely been organic growth that -- with patients that would have otherwise probably not been introduced to a vest but we're eligible. I think the study gives us an opportunity not to be so binary. There's no reason that we can't compete for share at the same time. So that's a new tool that we're equipping these sales reps with as we speak.
There's -- it's a big universe as we've talked about also with sales reps across the DME community. It's one of the reasons that we like the channel because the army is so big. But it also, I think, is indicating that we probably could use even more coverage. So we're going to add a few more people. We've got 12 or 13 salespeople. We're going to add a few more to make sure that we're providing the kind of coverage that we think that the market deserves but those are a couple of things that we'll be doing here in the back half.
Next question comes from the line of Suraj Kalia with Oppenheimer.
Dan, can you hear me all right?
Hear you fine, Suraj.
Guys, my apologies for the background noise. So Dan, may I quickly ask my two questions. So Dan, obviously, you talked about the number of reps, looking to add a few. Maybe I could just -- if I could ask for a baseline in terms of how should we think about utilization metrics per site, accounts per rep, revenues per rep, how should be going on? And also specifically, Dan, have there been any changes in sales rep commission structures, just to incentivize one way or the other. I'll hop here and pardon the background noise again.
Sure. Thanks for the question, Suraj. Short answer on the commissions is no. I think that we've got the right incentives in place with the goal of making sure that we want to continue to expand the awareness within our communities and continue to help more patients. But from a productivity metric standpoint, I think that we'll continue to evaluate what are the right tools as we get a new leader in place that she's going to want to see. But overall, I think the best metric to use is if you look at roughly what our head count is, it's been flat and we've been delivering double-digit growth for the last couple of quarters. So that's probably the best reflection, I think, of expanding productivity. We've continued to liberate our salespeople from some of the in-home demos. We've got some of our patient trainers that are well equipped to be able to educate and introduce the devices to patients and as we can more resourcefully deploy them where it makes sense. It gives the sales rep more time to do their market development and education of the HCP community.
And I think that we're seeing some reflections of progress there for sure. But with sales expense down year-over-year, head count relatively flat and lymphedema sales up 16%, those are, I think, probably the best macro metrics at a more granular basis. Certainly, our field sales managers pay attention to target accounts and new accounts and referrals per site but there's probably more detail than we get into on a call like this.
Next question comes from the line of Ryan Zimmerman with BTIG.
This is actually Izzy [ph] on for Ryan. So first off, I was just wondering if you could provide any updates on your ongoing head and neck trial. When could we expect to see some top line data from the trial? And roughly how large of an opportunity does this represent?
Sure. Thanks for the question, Izzi. So the head and neck RCT is advancing. This is the one, for those that are less familiar, where we're committed to tracking probably 200-plus patients against the standard of care. We expect to have somewhere north of 180 patients we will have enrolled by the end of this year. We hope to have the enrollment completed by the first part of 2024. And the follow-up is a handful of months. So probably at 2025 to get to the point where we have the expected results published and the kind of impact that we hope that it will have on payers. This will be, by far, the largest RCT done, we believe, in the space and certainly, by any measures in this head and neck community of cancer survivors.
We've said that it's about 10% of cancer survivors would be head and neck. So kind of frames a little bit there. And we certainly think that it can be a meaningful contributor to us probably as we get later into 2025. One of the considerations that we made and we kind of thought about what our 2025 revenue targets were going to be when we had those established back last fall.
Great. And just one follow-up. So I heard your comments on the engagement of the Kylee app and it sounds really encouraging. But what is the tangible benefit that you guys are seeing in sales given the engagement level?
Well, I think that it's still emerging. One of the things that we do believe is that continuing to be able to communicate with these patients, we'll be able to identify how well they're doing and if and when they're going to need to graduate to another device. So their ability to record their sessions, their measurements, even capture photos, we think, is going to make it much more compelling, if and when they would be eligible for an advanced pump.
I think the other piece that we still expect we're going to be able to benefit from and this one is coming, is some of the order management process is also one of the areas that we want to expand our Kylee application. Our ability to engage with patients more so the way that we would with your favorite airline app where you can place your order, you can change your order, you can check your status. And I think that those can help reduce cost to serve, while at the same time, allowing us to actually improve the engagement that we have with patients in whatever time line and format that they prefer.
So there's a component of operational exchange that is still ahead. But in the meantime, we think that the ability to continue to educate patients is a good way to continue to expand the universe of patients that can get a diagnosis and then ultimately, treatment.
We are currently seeing no remaining questions at this time. That does conclude our conference for today. Thank you for your participation.
Thank you, everyone.