IQVIA Holdings Inc. (IQV) Q2 2021 Earnings Report, Transcript and Summary

Ladies and gentlemen, thank you for standing by. At this time, I would like to welcome everyone to the IQVIA Second Quarter 2021 Earnings Conference Call. [Operator Instructions]. As a reminder, this call is being recorded. I would now like to turn the call over to Nick Childs, Senior Vice President, Investor Relations and Corporate Communications. Mr. Childs, please begin your conference.

Thank you. Good morning, everyone. Thank you for joining our second quarter 2021 earnings call. With me today are Ari Bousbib, Chairman and Chief Executive Officer; Ron Bruehlman, Executive Vice President and Chief Financial Officer; Eric Sherbet, Executive Vice President and General Counsel; Mike Fedock, Senior Vice President, Financial Planning and Analysis; and Brian Stengel [ph], Associate Director, Investor Relations. Today, we will be referencing a presentation that will be visible during this call for those of you on our webcast. This presentation will also be available following this call in the Events and Presentations section of our IQVIA Investor Relations website at ir.iqvia.com. Before we begin, I would like to caution listeners that certain information discussed by management during this conference call will include forward-looking statements. Actual results could differ materially from those stated or implied by forward-looking statements due to risks and uncertainties associated with the company's business, which are discussed in the company's filings with the Securities and Exchange Commission, including our annual report on Form 10-K and subsequent SEC filings. In addition, we will discuss certain non-GAAP financial measures on this call, which should be considered a supplement to and not a substitute for financial measures prepared in accordance with GAAP. A reconciliation of these non-GAAP measures to the comparable GAAP measures is included in the press release and conference call presentation. I would now like to turn the call over to our Chairman and CEO, Ari Bousbib.

Thank you, Nick, and good morning, everyone. Thank you for joining today. This morning, we reported second quarter results with outstanding double-digit growth in all key financial metrics. Following the strong performance, we've once again raised our guidance for the year. As you recall, we're tracking ahead of our pre-COVID V 22 financial plan. The health of the life sciences industry continues to strengthen. New clinical trial starts are trending well above recent historical figures. They are up 22% versus 2020 levels and up 7% compared to 2019. The pipeline of late-stage molecules continues to expand to record numbers, indicating a large backlog of potential launches, some of which have been pushed to the right during the pandemic last year. And finally, biotech funding continues to increase significantly. According to the National Venture Capital Association, funding totaled $25 billion in the first half of 2021. This represents an increase of 64% compared to the first half of 2020, which itself was already a record first half year. During 2020, the pandemic disrupted execution of clinical trials and businesses requiring face-to-face interactions. But at the same time, it accelerated change in the industry. It created new demand for new services. And IQVIA is uniquely positioned to deliver based on the differentiated capabilities such as data analytics, advanced technology offerings, and of course, our deep scientific and therapeutic expertise, all of which capabilities were highlighted to our clients during the pandemic. We are confident that these capabilities will continue to drive strong demand for both our clinical and commercial offerings in 2021 into 2022 and beyond. As we begin thinking about our plans during 2022, I am pleased to announce that we will be hosting an investor conference in New York City on November 16, where we will update you on our V 22 progress and share our plans for the next phase in IQVIA's evolution. Nick and the team will, of course, provide more details once all the logistics are set and available. With that, let's review the second quarter in more detail. Revenue for the second quarter grew 36.4% on a reported basis and 33.2% at constant currency. This represents growth that was $176 million above the midpoint of our guidance range. About 40% of this beat came from strong operational performance, and the remainder was from higher pass-throughs. Second quarter adjusted EBITDA grew 49.5%, reflecting the revenue growth drop-through as well as productivity measures. The $20 million beat above the midpoint of our guidance range was entirely due to the stronger operational performance. Second quarter adjusted diluted EPS of $2.13 grew 80.5%. That was 8% above the midpoint of our guidance range and was driven entirely by the adjusted EBITDA drop-through. Let me provide a little more update and color on the business during the quarter. Starting with our real-world evidence business. It once again performed well, strengthening its leadership position. This included a recent win with a top 20 pharma client to develop an ophthalmology evidence platform for upcoming product launches. The platform integrates primary and secondary data and layers on AI/ML tools to monitor patient safety in realtime. This will allow this client to add new products and indications to the platform without initiating new studies. This, of course, will save critical amounts of time and money while also reducing the burden on patients and sites. Turning to our commercial technology business. It continues to increase penetration among top 10 life science companies and emerging biopharma clients. A top 5 pharma client entered during the quarter into a commercial agreement to leverage the IQVIA human data science cloud as part of their core data and digital strategy for one of their large therapeutic areas. This client plans to roll out this platform in over 50 countries to centralize all of their fragmented data assets, resolve data management complexities and improve speed to insights. Our orchestrated customer engagement offering, OCE, gained additional ground this quarter as 9 new clients adopted the platform for commercial operations, including 2 wins with large biotech clients. One of these OCE biotech clients has the potential for a global rollout to over 20 countries. The other large biotech win represents a competitive win back of the customer-facing team in the U.S. To date, we have 159 client wins for OCE. Our clinical technology solutions team continued our path to innovation in decentralized clinical trials with the introduction of IQVIA's Clinical Data Analytics Suite or CDAS. This solution builds on our human data science cloud platform, provides life science companies with new approaches to data use and harmonization as well as producing AI/ML and analytics-based insights. As an open scalable cloud platform, CDAS seamlessly works with sponsors' existing data archive and systems. We now have all of the top 10 and 18 out of the top 20 pharma clients using at least one of the several modules within our clinical technology suite. By connecting the right technology with the right data sources, IQVIA is enabling customers to identify new opportunities to maximize product value, get to market faster, improve departmental and business alignment and reduce costs. Switching to our R&DS business. During the quarter, it continued to build on its strong momentum, with over $2.5 billion of net new bookings on a 606 basis. In the quarter, we achieved a contracted net book-to-bill ratio of 1.34 including pass-throughs and 1.37 excluding pass-throughs. As of June 30, our LTM contracted book-to-bill ratio was 1.45 including pass-throughs and 1.40 excluding pass-throughs. Our contracted backlog in R&DS including pass-throughs grew 16.7% year-over-year to $23.9 billion as of June 30, 2021. As a result, our next 12 months' revenue from backlog increased to $6.6 billion, which is up 19.6% year-over-year. I want to highlight the lab business, which continues to be a key driver of growth and, therefore, will remain an area of strong investments for IQVIA. You'll recall that on April 1, we completed the acquisition of the remaining interest in Q2 Solutions from Quest Diagnostics. Following this transaction, we announced our plans to expand our laboratory operation in Scotland to bolster our investment in cutting-edge technology, including next-generation genomic sequencing and testing. Also in the quarter, we agreed to acquire Myriad RBM, adding to our capabilities in the lab. RBM specializes in biomarker detection and quantification testing that supports early- and late-phase drug development in key therapeutic areas such as oncology, CNS and immunology. This acquisition fits nicely into our strategy to develop specialized testing and precision medicine to help support drug development with state-of-the-art solutions. These actions further demonstrate our commitment to advancing outcomes in this space, and we are excited to continue to grow and innovate in the lab business. The Myriad RBM transaction is expected to close sometime in the third quarter. I'll now turn it over to Ron for more details on our financial performance in the quarter. Ron?

Yes. Thanks, Ari, and good morning, everyone. Let me first start with revenue. Second quarter revenue of $3.438 billion grew 36.4% on a reported basis and 33.2% at constant currency. First half revenue was $6.847 billion, growing at 29.8% reported and 27% at constant currency. Our Technology & Analytics Solutions revenue for the second quarter was $1.353 billion. That was up 22% reported and 17.9% at constant currency. For the first half, Tech & Analytics Solutions revenue was $2.701 billion, up 21.3% reported and 17.5% at constant currency. R&D Solutions second quarter revenue of $1.891 billion was up 53.1% at actual FX rate and 50.7% at constant currency. Now excluding the impact of pass-through, second quarter R&DS revenue grew 44.6% year-over-year. For the first half, revenue in R&D Solutions was up 44.5% reported and 38.5% at constant currency. CSMS revenue of $194 million in the quarter grew 9.6% reported and 7.3% on a constant currency basis. And that brings the first half CSMS revenue to $387 million, up 3.8% reported and 1.3% at constant currency. And moving down the P&L and going to adjusted EBITDA. That was $722 million in the second quarter, which represented growth of 49.5%, bringing first half adjusted EBITDA to $1.466 billion, up 40.3% year-over-year. Second quarter GAAP net income was $175 million, and GAAP diluted earnings per share was $0.90. For the first half, we had GAAP net income of $387 million or $1.99 per diluted share. Adjusted net income was $416 million for the second quarter, and adjusted diluted earnings per share grew 80.5% to $2.13. For the first half, adjusted net income was $841 million or $4.32 per share. Let's turn briefly to R&D Solutions. As Ari mentioned, we delivered another outstanding quarter of net new business. We see backlog grew 16.7% year-over-year to $23.9 billion at June 30. And next 12 months' revenue from backlog at June 30 stood at $6.6 billion, up 19.6% year-over-year. Okay. Now on to the balance sheet. At June 30, cash and cash equivalents totaled $1.8 billion, and debt was $12.3 billion, which results in net debt of $10.5 billion. Our net leverage ratio at June 30 came in at 3.74x trailing 12-month adjusted EBITDA. Cash flow was again strong in the quarter. Cash flow from operations was $539 billion -- million and CapEx was $145 million, resulting in free cash flow of $394 million. This brought our free cash flow for the first half of 2021 to over $1.1 billion, which is a material improvement over our 2019 and 2020 results. In the quarter, we repurchased $45 million of our shares, leaving us with $822 million of share repurchase authorization remaining under our latest program. And now on to guidance. We're raising our full year 2021 revenue guidance by $275 million at the midpoint, reflecting the strong second quarter and the continued operational momentum that we see in the business. Our new revenue guidance is $13.550 billion to $13.700 billion, which is year-over-year growth of 19.3% to 20.6%. I would note there's no FX impact versus our previous guidance. Compared to prior year FX continues to be a tailwind of 150 basis points to full year revenue growth. Looking at the segments. We continue to expect full year Technology & Analytics Solutions revenue to grow low to mid-teens and R&D Solutions revenue to grow mid- to high 20s, while we now expect the CSMS business to be up low single digits. You saw that we also raised our profit guidance. As a result of the stronger revenue outlook, we've increased our full year adjusted EBITDA guidance by $43 million at the midpoint. Our new full year guidance is $2.950 billion to $3 billion, which represents growth of 23.7% to 25.8%. Moving to EPS. We adjusted our -- excuse me, we increased our adjusted diluted EPS guidance by $0.18 at the midpoint. Our new guidance range is $8.70 to $8.90, which is growth year-over-year of 35.5% to 38.6%. Our full year 2021 guidance assumes that June 30 foreign currency rates remain in effect for the second half. Now to review the revenue guidance for the third quarter. Third quarter revenue is expected to be between $3.290 billion and $3.365 billion, representing growth of 18.1% to 20.8%. We expect adjusted EBITDA to be between $710 million and $730 million, up 17.5% to 20.9%. And finally, adjusted diluted EPS is expected to be between $2.06 and $2.13, growing 26.4% to 30.7%. And again, our third quarter 2021 guidance assumes June 30 foreign currency rates remain in effect for the quarter. So to summarize, we delivered very strong second quarter results. We had double-digit growth in all key financial metrics. We posted revenue growth of over 20% in our TAS segment and over 50% in R&DS segment. R&DS backlog improved again to $23.9 billion, up 16.7% year-over-year. Next 12 months' revenue from that backlog increased to $6.6 billion. That's up 19.6% year-over-year. We reported another strong quarter of free cash flow. And given the momentum that we see in the business and our strong second quarter results, we're once again raising our full year guidance for revenue, adjusted EBITDA and adjusted diluted EPS. So with that, let me hand it back over to the operator for questions and answers.

[Operator Instructions]. Your first question comes from the line of Eric Coldwell with Baird.

I have two questions. Ron, first, congrats on the great cash flow performance year-to-date. I'm just hoping you can give us some more details on where you're making the biggest gains, changes supporting these improvements? And any color commentary on your outlook for the future? Second question, just COVID-related. It's the typical standard ask: if you could give any insights on COVID revenue in the quarter, bookings, backlog, thoughts on the tail end of 2022, that would be helpful as well.

Sure. To your first question, Eric, on cash flow, there are two principal drivers of our strong cash flow performance. The first, of course, would be our earnings growth, which was quite good. But beyond that, we've made substantial progress and continue to make progress in reducing our days sales outstanding. We've had a real focus on that over the past year, bringing down past dues, improving our billing terms with customers, billing sooner because we have substantial unbilled amounts. And all of that has contributed to strong collections. The one caveat I would say is that some of the COVID-related work does come with some advances that will burn off over time. So we're still targeting to have cash flow in any given year in the range of 80% to 90% of adjusted net income. Now obviously, substantially stronger than that so far this year. I think it's probably about 125% for the first half. And if we can beat that 80% to 90% range, great, but I think that's a good kind of medium-term sort of target for cash flow in a normal environment. But we're very happy with the progress we've made on cash flow and expect cash flow to continue to be strong for the future.

Yes. I mean, Eric, this is -- thank you for highlighting that aspect of our performance in the second quarter. As you know, we were not happy with our cash flow performance back in 2000 -- I guess, in '18, our total yearly free cash flow was $600 million. So just barely half of what the first half performance was this year. In '19, I think it was around $800 million. And last year, in 2020, we bumped that up to $1.3 billion or thereabouts. So we're very, very pleased with our performance, and just for the reasons that Ron highlighted, especially grateful to the finance team for focusing on the management of our receivables, collections and generally, bill-to-cash type of process improvements. That took a lot of efforts but we think we'll continue to pay dividends. We also remember had committed to investors that we would reduce our leverage ratio from the mid- to high 4s on a net basis to 4 or less by the end of 2022. And I would note that for 2 quarters in a row, we are below that for probably a year earlier. Now again, we might see the average ratio move up and down, depending on circumstances and our spend on M&A and share repurchases. But that's where we are, and we're very pleased with that performance. The second question you had was on COVID work and how much it represents. I think it's always probably best to look at how much COVID work is in our backlog. And I just want to say that the total -- the large COVID vaccine trials which have represented the bulk of our work in COVID, represent less -- actually much less than 5% of our total backlog. And so that gives you a sense. And in terms of -- now having said that, we expect COVID work to continue to remain part of our business for the foreseeable future. We expect COVID studies to have a long tail through 2021, well into 2022 and perhaps 2023. There will be a need for vaccines for multiple manufacturers. We still have, in our pipeline, RFPs for vaccine work from different companies around the world. There are new vaccines being developed for the variants. There are alternative vaccines that are being needed for adverse safety events, quality issues, manufacturing delays. And then there are a bunch of novel treatment programs that are targeting specific populations and conditions. So all of that is still in our pipeline. But again, the large vaccine work is less, way less than 5 percentage points of our total backlog including pass-throughs. So any other commentary you want to make on revenue or impact are really not significant.

Well, look, even if you were -- on the revenue side, if you were to pull out all of the COVID-related work, we still have very strong revenue growth, double-digit revenue growth in both the TAS segment and the R&DS segment. So yes, COVID was a contributor in the quarter, but the underlying non-COVID-related work was growing strongly also. And of course, COVID is the reality these days. It's part of the business. We want to participate in that work, and we have been participating in that work.

Your next question comes from the line of Shlomo Rosenbaum with Stifel.

I have two questions. One is more of a housekeeping thing. Ron, maybe you could provide the precise organic revenue growth? metrics for each segment, TAS and R&DS. And then secondly, I wanted to ask you a little bit more about what Ari started out with in terms of the growth in the real-world evidence business. What's the size of the business at this point in time? What was the growth in the quarter? How is that contributing to the overall business growth? And just more detail, it seems like that's a significant differentiator for IQVIA versus a lot of the competition. I thought we could flesh some of that out.

Let me take the first question, Shlomo, on organic growth. The contribution of acquisitions in the quarter to our revenue growth was insignificant. If you look back over the past number of quarters, you can see our acquisition activity tailed off quite a bit and is only recently beginning to pick back up. So there's almost no contribution whatsoever of acquisitions to our growth. So organic growth, for all intents and purposes, equals reported growth in those segments.

Yes. And then, Shlomo, on the real-world side, that business is about $1 billion. As we've talked about before, continues to grow double digits. This quarter was high double digits again. Continue to see very, very strong results in that business and continue to deliver for us and drive the pass-through.

Your next question comes from the line of John Kreger with William Blair.

Maybe just a quick follow-up on real-world evidence. I think prior -- previously, this year, you'd talked about doing some significant government COVID tracking work, but that was expected to tail off. What are your current thoughts about the durability of that program? And sort of what are you assuming in your guidance for the year?

John, we're expecting that work to continue through the balance of the year, but it will be less contribution in the second half than the first half. We'll see whether it continues on into 2023 or not. That sort of work tends to be pretty quick burn and rapidly changing, but we do expect some incremental contribution from the government COVID-related work through the balance of the year. Think particular, when you get into the fourth quarter, the compare to last year's fourth quarter when we had a substantial amount of it is going to be negative. But you see overall, for our implied fourth quarter guidance, that it remains very strong for the company as a whole.

Ron, that's helpful. And maybe a follow-up. Can you guys just talk a little bit about the staffing environment? We hear a lot about labor shortage. Just curious if you're seeing any constraints in your ability to recruit and hire and if that's driving any pressure on margins.

Yes. Look, it's no secret that given the strength of the industry backdrop, there's obviously strong competition for talent. And it's also no secret that when people need highly qualified talent, they come after IQVIA talent because they know we train people well, and we've got a broad range of skills and training programs. So -- however, we are confident that we'll continue to be able to attract and retain the talent, simply because we are the premier company in the industry and also, frankly, because we've been investing in our employees, especially during the pandemic. We've been looking after our employees. We didn't restructure. We continue to pay our people well. Now does it cause a certain amount of anxiety in the industry? And yes, it's true. And has it caused some level of wage inflation? Yes, that is true. There is also a little bit of an uptick in attrition levels as a consequence of all of that. All of that is true. But again, we feel confident. We do not anticipate this to cause any significant -- there will be some level of headwind to our margins, but we have so many programs and productivity measures and process improvement measures in place that we are confident we will overrun. And you could see that our margins have been performing very well and growing faster than we had anticipated.

Yes. John, obviously, any cost pressure we're feeling is fully baked into our 2021 guidance.

Your next question comes from the line of Tycho Peterson with JPMorgan.

Ari, on the 16.7% backlog growth, I'm just wondering if you could provide any more color. How much of this, in your view, is kind of pent-up demand, catch-up work? And then any kind of lingering concerns around site accessibility and the variant potentially impacting conversion in the back half of the year?

Well, obviously, you've got a compare issue quarter-over-quarter that's driving some of that -- those just unusually high growth rates. But I think we've got a combination of a lot of factors: one, catch-up work. You're correct. I mean there's a lot of work that was done last year remotely. And we still need to have site document -- on-site document verification activities that need to take place. So that's another boost to our growth. Thirdly, there is the simple fact that projects that were supposed to get started last year were pushed to the right. And so that also has a demand. Fourthly, we've been gaining market share. We've been saying it over and over again. And I think the numbers are pretty clear. Given our consistently higher book-to-bill ratios and the size of our revenues, I think the math clearly will indicate that we are gaining share. And we are now beginning to execute on all of these projects that started with some delay last year. And finally, there is the COVID work. So all of that contributes to this very strong growth rates that we have reported. Your other question which were operational metrics, site access and so on. Look, we are essentially -- I think we could say about 80% or so or approaching 80% into the site access. Given all the flareups, infection grows in different parts of the world. But our guidance for 2021 takes a lot of factors into account, including site accessibility. We also believe we are at a -- some kind -- at critical mass. In other words, at 80%, we can deliver, with a combination of different methods we have perfected in terms of remote visits and so on. It's good to monitor site access as a metric when it sets in the general recovery, but they don't correlate exactly with revenue recognition. There's many other metrics we track: the site startups, which have essentially returned to the baseline of 2019; patient recruitment, which are running at or above the 2019 averages; patient visits, which are essentially close to the pre-pandemic levels. So all of those -- bottom line, these metrics provide us with the confidence that the non-COVID trial pipeline is not only being awarded, as exemplified by -- as illustrated by our strong bookings, but also, it's starting to be delivered, meaning the sites are enrolling, the patients are enrolling and the patient visits are taking place. So I hope that clarifies where we are operationally in R&DS.

That's helpful. And then for a follow-up, 2 quick ones. I'm wondering if you can update us on the orchestrated clinical trial rollout, how that's going. And then separately, on the acquisitions. I understand they're not big revenue contributors. I'm just curious if the accretion assumptions have changed. I think you've previously talked about $0.12 accretion from the Q2 acquisition. I just want to make sure that's still case.

You ask about decentralized, right?

That's what's -- okay.

Yes. That, we'll see here. Yes. Again, on the acquisition, just to clarify, on the 40% acquisition of the minority Q2 of the lab that we didn't own, there was 0 impact on revenue and EBITDA since we already consolidated as we were 60% owner. But there was this accretion on -- there's accretion on the bottom line. And all of the accretion, you have the exact number for the base -- for Q2?

$0.12.

For the balance of the year?

For the balance of the year. We put that into our guidance.

That's in the guidance?

Yes.

That was already done.

That was already done.

By the time. Nothing has changed on -- now I'm not clear on your first question. Was it about the centralized trials, about OCT?

It was about the orchestrated clinical trials, OCT, the suite launch and how that's going.

Okay. Fine. So that's going well. I mentioned in my introductory remarks that every single one of our -- of the top 10 pharma clients is using 1 module of our clinical technology suite and 18 of the top 20. So we are gaining ground and making progress. The -- essentially all of the suites have been launched and most modules are being used, and the sales pipeline continues to increase. We see a lot of interest from our clients for the platform itself and also for individual or suites stand-alone modules. We're seeing interest from all customer segments. I talked about the top 20, but it's also true for the mid- and EVP. We have demands for multiple products within the digital patient suite. Some of that is driving some of the growth that you saw on the TAS business. The CDAS suite, which I talked about in my introductory remarks, is -- the Clinical Data Analytics Suite connects structured and nonstructured data from clinical trials into a central repository that creates one version of the truth that allows predictive analytics to be run, et cetera. It's a key benefit for clients, which, as you know, the big vaccine issue in health care is the interoperability of data between customers, between the people who run the trials, like IQVIA in this case, and various competitive applications and data sources. So the CDAS product eliminates the need to reconnect individual applications to each other. And instead, these applications, they connect directly to CDAS and enables to harmonize the data and provide an intuitive and scalable solution to map multiple clinical data sources, enables us to use AI/ML layers of analytics using this single-data ecosystem. So we are very pleased with the progress. Our clients are beginning to understand the value, and we are beginning to penetrate that customer base. Thank you.

Your next question comes from the line of Jack Meehan with Nephron Research.

Ari, I was hoping you could give a little bit more color on the progress of OCE to now 109 clients. What's the revenue base for this business? And where do you think you are in the growth curve? Is it still in investment mode? Or has the business turned profitable at this point?

Right. I don't think we disclosed how much it represents. But we've said that so far in 2021, we've had 19 client wins, which brings the total since launch, 3.5 years ago, to 159 client wins. We continue to have a disproportionate share of the wins. I think it's 2 out of 3, and that has been consistent. We are performing well with the large pharma deployments, which we have talked about. I think Roche already has 15,000-or-so users in deployment. So we haven't seen any slowdown in the implementation as a result of COVID other than isolated issues, which we dealt with. We even see some deployments that are -- that have accelerated time lines. So the feedback is overall positive. The field reps are very engaged. All is going better than planned for the launch of OCE, which I remind you, was only 3.5 years ago.

Great. And then you started by talking about the strength of the funding environment and the VC activity going on. I was wondering if you're seeing any themes emerge from a therapeutic area perspective and how you thought IQVIA was stacked up for that. And one specific area I was hoping you could weigh in on is Alzheimer's and just whether you think that's an area where you could see new investment coming in.

I think, look, the -- undoubtedly, the area where we see the most funding is oncology, especially those subcategories of oncology where it's been difficult to have effective drugs. So people are pouring a lot of VC funds into oncology. CNS is another area. And Alzheimer's, yes, we've got quite a few things going on there. Cardiovascular, strong growth as well. So I would say these are the -- and of course, immunology, prompted by what happened with the virus and COVID. There's a lot of interest in immunology, and that also, I would say, is the fourth main area of funding.

Our next question comes from the line of Dan Leonard with Wells Fargo.

So hoping, first, you could elaborate a bit more on your decentralized trial offering and maybe update specifically on Study Hub trends.

Yes. I mean, look, as we mentioned, the decentralized trial opportunity was identified well before COVID. We talked about it before. We used to call it virtual trials, hybrid trials. We talked about it and we felt we were making great progress. And then the pandemic happened, and we saw how critical those capabilities were, and that accelerated the development. Basically, it's a combination of remote technologies and digital -- the part of the clinical trial that can be digitized. So the suite, for us, combined eConsent, which you're familiar with, telemedicine, modules, eCOA, and of course, a lot of digital communication. It basically optimizes and virtualizes the relationships between local labs, health care providers when it's necessary. It sort of establishes a virtual network of investigators and care professionals. And what we do is that we agree on preset terms with the investigators that agreed to participate. We have internally operationalized this business and we have a separate team, a decentralized trial team. For example, we've got decentralized clinical trial, clinical research coordinator that can support the sites in a remote way, help navigate technology. This is new for all of the investigators and certainly for the patients. So we need -- we figured out during the pandemic that we needed a centralized team to assist sort of, kind of a help desk, if you will. There are -- there's also -- so there's kind of a sort of a wide growth service to help patients and sites through the decentralized trial process. We also have research nurses and phlebotomy solutions team that build on our global network to support the decentralized studies. So again, we are moving to -- from -- we moved from the pre-2020 piloting phase where we had, I believe, at the time, sort of 60-or-so small trials that essentially were experimental in nature and people wanted to sort of try it out to a maturing phase. We have added many wins. We've -- so far in 2021, I think we have more than a dozen larger decentralized clinical trials that were won. We added new therapeutic areas. We are working with 5 of the top 10 large pharma clients. And I would note that one of the reasons we were able to win so many, a bigger proportion than anyone else of the COVID work, whether it's therapeutic trials or vaccine trial, was our more advanced decentralized trial capability. And again, we cover probably 10-or-so therapeutic areas, nephrology, oncology, psychiatry, CNS, dermatology, et cetera. And it's moving to a more mature phase, and we will speak more about that in the future. Again, in the context of the very large R&DS business we have, it's still not something that's kind of moving the needle in the numbers. Given the very strong growth that we have, it's not materializing. Ron, do you want to add...

Yes. Just to put some numbers around what Ari just said, I think we had 81 trials now that are fully deployed on Study Hub. And there's approaching 250 trials or so that have some piece of Study Hub. And at any given point in time, we'll have close to 1,000 full-service clinical trials going on. So it's a piece of our business -- it's a growing piece of our business, but still not the majority of what we're doing.

Okay. That's very thorough and helpful. And just a quick follow-up to Jack's question earlier. Possible -- I'm curious if you could frame and size the Alzheimer's opportunity for IQVIA. I remember when something had to come out of backlog a couple of years ago, it was rather sizable and been wondering how sizable things coming into backlog could be.

Yes. I don't think it's -- listen, at the time, our bottle was much smaller. When we came out, it was sizable, but it -- we didn't -- it was, like, seamless. We never felt it. It was not an issue at all, neither when it left nor when it came back partially. So I'm not sure what you're referring to. It's not significant. I don't if we disclosed that, but it's not -- it wouldn't be material and would be in the rounding given the size of our backlog.

Yes. The current Alzheimer's contribution of our backlog is not material. Now could there be more coming in the future? Sure, we hope there is, but we'll see.

Your next question comes from line Patrick Donnelly with Citi.

Ari, you touched on M&A a little bit, and obviously, the cash flow performance, where the leverage is. Can you just talk about kind of the landscape, what the pipeline looks like? Obviously, a lot of activity in the space. And then secondarily, given some of the mergers and movements around the space, are you seeing any disruption opportunity for share gains? Any commentary from customers suggesting this is an opportunity for you guys at the moment?

Yes. I mean the latter part of your question refers to the consolidation. And soon enough, we're going to be the only one standing here that's independent. But we -- look, generally, the clinical trial business is an attractive area. It's a high-growth area. It's something that's, well into the long term, going to deliver superior returns, we believe, as an industry, and that is attracting a lot of interest from buyers, whether it's private equity or other large entities that want to -- are in search of accelerate -- opportunities to accelerate their revenue or profit growth. So that -- all of that is good news for our industry. In terms of what are the consequences strategically, operationally, I think it's pretty clear that -- first of all, we don't need to "participate." Obviously, we look every time, and most of these companies have been shopped to us obviously. We look at these companies. And in cases, we've passed because we think the valuations or our ability to gain share does not require us to buy or to participate in this M&A trend. It's hard to gain a lot when you -- for a CRO to acquire another CRO. I mean there are opportunities to complement capabilities, whether it's therapeutic-wise or geographic-wise, that could be areas of the business, preclinical Phase I, Phase II, Phase III complementary strengths. So again, these are the 3 dimensions: geography, therapy areas or stage in the drug development process that could lend themselves to more or less complementarity overlap. Now the consolidation has taken place thus provide opportunities. As you know, I said before, we have been, like, gaining share significantly so we don't need to do that. It is a fact that when there is a large merger or large acquisition, there is disruption. We believe it ourselves. So there is generally a loss of talent. We are seeing it for -- coming from others. And there is, generally, a desire by customers to keep 2, 3 or 4 providers. And so if providers overlap when they serve the same customer, you can expect that the sponsor will look to further diversify their provider base. So all of this is true. Look, we -- both talent and customers are -- present opportunities, but we're not so focused on this. We just -- we're focused on executing on our strategy. It's worked so far, and we're confident it will continue to work. Other acquisitions, obviously, we're looking at things. As always, there's a rich pipeline always. You've noted we haven't done much last year. We haven't done much this year so far, save for the Q2 minority acquisition. But we are looking at other things, always in the technology space. And we have a rich pipeline. It's just -- it's a binary thing. Acquisition happen or they don't happen. So I can't really talk much about that.

No. That's helpful. And maybe just a quick follow-up. CSMS doesn't get the most airtime, but it's nice to see the recovery ongoing. I think you bumped guidance from low single-digit declines to low single-digit growth. Can you just talk about the market recovery going on there and the outlook?

Yes. I mean, look, a lot of clients did not cancel contracts last year because they didn't know how long this was going to last. And while our field reps weren't able to actually be in the field, but many of them remained on the bench with contracts kind of suspended or renegotiated. That caused some disruption. And as we have begun turning the business around but -- so it slipped and went back into the red in terms of revenue growth. But now we're seeing that we are going back -- and I mean, look, this is never going to be a double-digit grower, I don't think. So this is the best it's going to be, single-digit growth. And we are managing it. It's becoming less of a flash point, simply because in the size of our company and the growth of the rest of the business, this is becoming relatively small. Now look, you will recall that we -- shortly after the merger, nearly 5 years ago, we tried to sell it as a whole. We then found that it wouldn't fetch much of a value. And therefore, we pulled the business, integrated it into our regions. It's very integrated now into our commercial operations. There are contracts which is very useful. In fact, I've mentioned before, the decentralized trial business, where we are using nurses from that -- from the CSMS business to help with the virtual aspects for the -- going to visit patients at home and so on. So there's kind of an added value. It's not going to move the needle one way or the other as it used to be in the old Quintiles days or in the early IQVIA days. Okay. Last question, Nick?

Last one, yes.

Our last question comes from the line with Sandy Draper with Truist Securities.

This should be a pretty quick one. Ron, just when I look at the third quarter guidance, looking down sequentially, I just want to confirm, I would assume most of that is because of an expected decline in pass-through revenue and R&D. Is anything else...

Yes. That's really the driver. You're correct, Sandy.

Okay. That's my question. Congrats.

Thank you, guys.

That's it. Well, thank you, everyone, for joining us today. We look forward to speaking to all of you again on our third quarter call. Me and this team will be available later for any follow-up calls you -- follow-up questions you might have and look forward to talking to you. Thanks, everyone.

This concludes today's conference call. You may now disconnect.