Good day, and thank you for joining us on this call covering the quarter ended June 30, 2022. Also on the call today, we have our CEO, Dr. Steve Cutler, and our CFO, Mr. Brendan Brennan. I would like to note that this call is webcast and that there are slides available to download on our website to accompany today's call. Certain statements in today's call will be forward-looking statements. These statements are based on management's current expectations and information currently available, including current economic and industry conditions. Actual results may differ materially from those stated or implied by forward-looking statements due to risks and uncertainties associated with the company's business, and listeners are cautioned that forward-looking statements are not guarantees of future performance.
Forward-looking statements are only as of the date they are made, and we do not undertake any obligation to update publicly any forward-looking statement, either as a result of new information, future events, or otherwise. More information about the risks and uncertainties relating to these forward-looking statements may be found in SEC reports filed by the company, including the Form 20-F filed on March 1st, 2022. This presentation includes selected non-GAAP financial measures, which Steve and Brendan will be referencing in their prepared remarks. For a presentation of the most directly comparable GAAP financial measures, please refer to the press release section titled condensed consolidated statements of operations. While non-GAAP financial measures are not as superior to or a substitute for the comparable GAAP measures, we believe certain non-GAAP information is more useful to investors for historical comparison purposes.
Included in the press release and the earnings slides, you will note a reconciliation of non-GAAP measures. Adjusted EBITDA excludes stock compensation expense, restructuring costs, foreign currency gains and losses, amortization, and transaction-related costs, and their respective tax benefits. We will be limiting the call today to one hour and would therefore ask participants to keep their questions to one each, with an opportunity to ask one related follow-up question. I would now like to hand over the call to our CFO, Mr. Brendan Brennan.
Thank you, Kate. In quarter two, ICON achieved gross business wins of $2.76 billion and recorded $441 million worth of cancellations. This resulted in net awards in the quarter of $2.32 billion and a net book-to-bill of 1.2. On a trailing twelve-month basis, our net book-to-bill was 1.25. With the addition of the new awards in quarter two, our backlog grew to a record $20 billion, representing an increase of 2.1% on quarter one of 2022, or an increase of 10.7% year-over-year on a combined company basis. Our backlog burn was 9.9% in the quarter, consistent with quarter one. Revenue in quarter two was $1.935 billion.
This represents a year-over-year increase of 122.1% or 129.9% on a constant currency basis. On a combined company basis, revenue increased by 0.9% or 4.4% on a constant currency basis from the comparable period last year. The revenue impact from year-over-year changes in foreign currency exchange rates resulted in a headwind of approximately $68 million in quarter two. Our top 25 customer concentration decreased slightly from quarter one, as our top customer represented 8.7% of revenue. Our top five customers represented 27.2% of revenue. Our top 10 represented 14.6%, while our top 25 represented 59.7%. Adjusted gross margin for the quarter was 28.4% compared to 27.8% in quarter one.
Gross margin increased sequentially due to increased operational efficiency and strong direct fee revenue growth. Total SG&A expense was $194.4 million in quarter two or 10% of revenue. We expect total SG&A expense to continue at a similar absolute dollar level as we progress through the second half of the year. Adjusted EBITDA was $354.3 million for the quarter or 18.3% of revenue. In the comparable period last year, adjusted EBITDA was $305.1 million on a combined company basis or 15.9% of revenue, representing a year-on-year increase of 16.1%. Adjusted operating income for quarter two was $328.6 million, a margin of 17%.
The adjusted net interest expense was $43.5 million for quarter two. Due to the increasing interest rate environment expected through the duration of the year, we are now anticipating full-year interest expense to total approximately $210 million. This represents an increase of approximately $50 million from our initial assumptions for the full-year interest expense when guidance was issued in January. The adjusted effective tax rate was 17% for the quarter. We continue to expect the full-year 2022 adjusted effective tax rate to be approximately 16.5%. Adjusted net income attributable to the group for the quarter was $235.8 million, a margin of 12.2%, equating to diluted earnings per share of $2.86, an increase of 24.4% year-over-year.
In the second quarter, the company recorded $8.9 million of transaction and integration-related costs. US GAAP income from operations amounted to $177.8 million or 9.2% of revenue during quarter two. US GAAP net income attributable to the group in quarter two was $115.7 million or $1.41 per diluted share, compared to $1.38 per share for the equivalent prior year period. Net accounts receivable was $875 million at June 30, 2022. This compares with a net accounts receivable balance of $745 million at March 31, 2022.
Cash collection efforts continue to be strong, with DSOs of 41 days in the quarter, down from 43 days on a comparable basis from June 30th, 2021, and up from 35 days on a comparable basis at March 31st, 2022. Cash generated from operating activities in the quarter was $182 million. At June 30th, 2022, the company had a cash balance of $614.9 million and debt of $5.046 billion, leaving a net debt position of $4.429 billion. This compared to net debt of $4.581 billion at March 31st, 2022, and net cash of $707.2 million at June 30th, 2021. Capital expenditure during the quarter was $28.2 million.
We ended the quarter with a net debt to trailing 12 months adjusted EBITDA ratio of 3.1x . From a capital deployment perspective, our priority remains on debt pay down in the near term, and as such, in quarter two, we made a payment of $100 million on our Term Loan B facility, bringing our total repayments to $400 million year to date. Given our continued strong cash flow generation, we remain well on track to exit 2022 below three turns of net debt to adjusted EBITDA. We are evaluating our capital structure to determine if a more optimal mix can be attained. We have not yet made any changes to our current structure, but we will continue to actively evaluate potential options through the course of Q3.
With all that said, I would now like to hand the call over to Steve Cutler.
Thank you, Brendan, and good day, everyone. ICON delivered strong results in quarter two while continuing to manage through a number of global macroeconomic factors that are currently impacting our business. The ongoing war in Ukraine continues to present operational challenges as we focus on supporting our employees, customers, and patients in the affected countries. Our priorities remain on ensuring the safety of our employees, as well as continuity for our customers' programs and the effective monitoring of patients on our trials. During the quarter, we saw a step-up of the impact to our business in both countries. At this time, and for the foreseeable future, we are not recruiting any new patients or starting any new studies in Russia or the Ukraine, but we are continuing to support in-flight trial work in both countries wherever possible. Additionally, COVID-19 continues to have an impact on the business.
The number of sites restricted in some capacity was approximately 15% at the end of the second quarter as new variants spread. Most significantly, the mandated lockdowns in China, which were in place for most of quarter two, presented challenges to site access, staffing, and also to our laboratory operations in the country. We now expect the full-year revenue impact from the war in Ukraine and COVID-related lockdowns in China to be approximately $60 million-$80 million. In addition to the conflict in Europe and China lockdowns, the strengthening US dollar and rising interest rate environment provided further macroeconomic challenges during the quarter, which will impact our results for full year 2022. Despite these current challenges, the underlying demand conditions in clinical development remain solid.
In the past month, we have seen more deliberate spending from select customers in the emerging biotech segment as they look to prioritize due to public market funding challenges. Given the more challenging macro environment for emerging biopharma companies, we see an opportunity to further penetrate this segment as companies seek additional strategic input and the most efficient clinical trial plans to maximize their clinical development budget. We also remain vigilant on what our customers we are working with and continue to perform consistent due diligence on their ability to fund trials before the contracting phase. As a result, we are pleased to report that we have not seen any unusual cancellation activity in our backlog or with ongoing trials. We believe the fundamentals in our industry are well intact, anchored by large and mid-sized biopharma companies continuing to grow their R&D spend in line with historic market rates.
On a trailing twelve-month basis, total RFP value was up mid-single digits in line with broader market growth. In addition, we see good evidence of venture capital and private funding supporting small biopharma companies that are developing drugs and devices on the basis of good science. We remain confident in our ability to continue to meet our financial outlook as our business development performance continues to deliver against our goals of a 1.2-1.3 book-to-bill, and our backlog growth accelerated to an impressive 10.7% year-over-year on a combined company basis. Our customer mix remains well balanced and consistent with prior periods, with approximately 50% of our revenue in large biopharma and approximately 45% of our revenue in small and mid-size companies.
Approximately 15% total company revenue and backlog is derived from the emerging biotech companies, which we define as those with less than $100 million of annual R&D spend. Additionally, we are encouraged by the number of strategic partnership opportunities that are currently in our pipeline with large and mid-sized biopharma, including full service, functional, and hybrid models of development. The clear benefits of our scale, depth, and breadth of service offerings and expertise, as well as differentiated technologies and analytics, are resonating well with new and existing customers. ICON's investment in areas such as advanced analytics, as well as decentralized clinical trial technology and services, have delivered innovative solutions that are enabling studies of the future. In the quarter, we completed a new release of the ICON Digital Platform, our purpose-built platform specifically designed to decentralize clinical trials.
This latest release included enhanced features on electronic clinical outcome assessments and electronic consent functionalities. We continue to integrate our related clinical services and technologies, Firecrest, Accellacare sites, home health services, Mapi assessment, and others, to further support harmonized integration of all patient data and services in a customized and flexible manner. In this way, we will provide a compelling solution that will enable us to provide a more efficient and faster clinical trial service to our customers. Turning to our financial results, performance was very good in the second quarter, resulting in combined company revenue growth of approximately 1% or 4.4% on a constant currency basis year-over-year. Excluding COVID revenue, growth was approximately 16% year-over-year on the same basis.
Operational performance was particularly strong in the quarter, with 16% adjusted EBITDA growth year-over-year on a combined company basis, driven by strong direct fee revenue growth as well as efficient resourcing and continued SG&A cost management. In addition, earnings per share grew an impressive 24% year-over-year. We are updating our full year 2022 financial guidance to reflect the impacts of macroeconomic factors on our expected results. The company now expects revenue to be in the range of $7,690 million-$7,810 million, an increase of 40.3%-42.5% year-over-year, or 3.1%-4.7% on a combined company basis.
This updated revenue range assumes foreign exchange rates at current spot rates for the second half of 2022 and reflects an anticipated incremental negative headwind of approximately $120 million-$140 million on revenue since our earnings call in April, as well as an additional impact from the combination of the ongoing war in Ukraine and COVID-related lockdowns in China. The combination of our direct fee revenue growth and realized cost synergies is driving accelerated margin expansion, which is expected to result in an adjusted EBITDA margin of approximately 19% for the full year, 100 basis points above our previous expectations. Further, we are narrowing our full year earnings per share guidance to a range of $11.65-$11.85, remaining at the same midpoint as our previous earnings per share range.
We continued our capital deployment strategy as expected by making a $100 million payment on our Term Loan B facility in the quarter, further reducing our leverage to 3.1x net debt to adjusted EBITDA at the end of the quarter, down from 3.3x at the end of quarter one. We believe we are on track to hit our aspirational target of exiting 2022 with a leverage ratio of approximately 2.5x adjusted EBITDA. Earlier this month, ICON passed another milestone in our transformational union with PRA Health Sciences by celebrating the one-year anniversary of the launch of new ICON.
We have made significant progress in our integration over the past year, and our highly effective team has met the challenge of bringing together two large organizations, all while continuing to focus on operational execution and project delivery for our customers. The response to new ICON has continued to be very positive from our customers, as evidenced by the number of new and expanded customer relationships that have been formed over the past year. I'm particularly proud to note that this integration has progressed with excellent customer retention, a testament to ICON's organizational commitment and execution in minimizing disruption for our customers. There have been numerous achievements from our team over the past year as we continue on our journey to become the world's leading healthcare intelligence organization.
One of our priorities at the outset was to enable a shared employee experience throughout ICON, and we are well on our way to achieving this through the rollout of key systems and platforms, as well as in areas such as benefits harmonization and career development and training programs. As of the end of quarter two, we have completed 60 facility integrations or closures over the past year, reducing costs, optimizing our office footprint, and bringing our staff together to allow for increased collaboration and engagement. We have an ambitious goal to be the recognized employer of choice in the industry, focusing on career development and growth opportunities for our employees. We believe we are seeing results of our targeted investments in areas such as talent acquisition, diversity inclusion, and retention programs that are translating to reduced attrition and stabilizing turnover levels throughout the first half of this year.
Due to the accelerated progress on integration efforts, we now expect to realize $100 million in cost synergies in 2022, an increase of $25 million over our previous target for the full year. Our targets for total cost synergies and revenue synergies of $150 million and $100 million respectively remain in place as we continue to focus our efforts to implement our global business services model and drive further success in cross-sell opportunities. With the acceleration of expected realized cost synergies in 2022, we now anticipate achieving our $150 million cost synergy target exiting 2023, 12 months ahead of our previous guidance. ICON has made great strides over the past year as we doubled the scale of our organization while continuing to deliver best-in-class performance to our customers.
With the ever-changing macro environment and growing complexity of clinical trials, we recognize the need for continued innovation and the importance of integrated and flexible solutions to meet customers' evolving needs. We remain committed to investing further in the critical data, technologies and talent to further enhance our service offering. Before moving to Q&A, I would like to take a moment to thank our dedicated employees for their ongoing commitment to our company, customers, and patients, and to recognize their significant efforts over the past quarter in driving the success of ICON plc. Operator, we are now ready for questions.
Thank you. Dear participants, as a reminder, to ask a question you need to press star one one on your telephone and wait for a name to be announced. Please stand by while we compile the Q&A roster. This will take a few moments. Now we're going to take our first question. The first question comes from the line of Elizabeth Anderson from Evercore ISI. Your line is open. Please ask your question.
Hi, guys. Thanks so much for the question. I was wondering two things. One, can you talk about sort of you know a little bit more in detail the sort of RFP and win rate by sort of customer type in the quarter? I know you alluded to some potential you know changes and sort of effort on biotech to sort of feel things out in terms of funding.
Can you also talk about, you know, I think you said that there was nothing unusual in the cancellations, but on our math, it looked like the cancellations kicked up a little bit in the quarter, and I don't know if there was like a specific program that perhaps didn't go or, something else you could provide in terms of that, so we can sort of think about the run rate going forward? Thank you.
Sure. Let me take the first one. Sorry, the second one first. In terms of cancellations, they did pick up slightly, but it was really around the down scoping of a couple of significant vaccine studies that we were working with and in fact starting to work on or putting forward. It wasn't. There wasn't anything that completely canceled. It's just these vaccine studies are large and they are somewhat changeable as they get planned. So we had a couple that had gone into the backlog, but then actually came out because they got down scoped, fewer patients. They're still moving forward, but at a reduced scope. That was the major sort of uptick or the driver for the uptick on the cancellation side of things.
Really nothing there that we saw as material in terms of, you know, taking stuff out. In terms of the RFP way, you know, I think we've got to be a little careful about RFPs. We do see them as somewhat directionally correlated with, you know, longer-term business performance. Really, I think when you look at quarterly numbers, they can vary quite significantly, and they can be quite volatile. You get a particular large RFP into a quarter which can skew the numbers quite a lot. I just wanna be a little careful with when we start quoting on the RFPs. As I said, they were up on a trailing twelve-month. I think trailing twelve-month is probably the best way to look at these sort of things.
We are up about mid-single digits for us. If you take COVID out, they were pretty flat. In terms of the segments, you know, we're certainly seeing a lot of positive move forward in our large pharma and mid-size. The biotechs were a little bit more attenuated, a little bit down year-over-year. Really overall, you know, we see a pretty solid and positive business environment. As I say, the RFPs, you have to be a little careful. You have wins, you have losses, and you have sort of cancellations within the RFPs. There's sort of a mid-teens, I suppose, proportion or percentage of RFPs that actually don't get to any decision.
You do have to be a little careful, I think, about how you interpret RFP data in this industry.
Okay. Super helpful. Maybe one just quick final one. I'm sorry if I missed it. Did you give the cross-sell number in the quarter?
No, we didn't give the cross-sell number in the quarter. We didn't. We weren't specific on that.
Would you like to?
I'm not sure if I have that. Do we have that?
Okay.
We're not far off our kind of running expectation on an annual basis.
I think overall, I think to date, we're at about $100 million in cross-sell ups from the close. That's in the year. That's pretty much in line with what we expected to do. We're on track with those, with the cross-sell. The revenue takes, of course, a little bit longer to flow through on those cross-sells. In terms of sales, we're in terms of year to date, we're on track.
Okay, perfect. Thank you so much, guys.
Thank you, Elizabeth.
Now we're going to take our next question. Please stand by. The next question comes from the line of Christine Rains from William Blair. Your line is open. Please ask your question.
Good morning, and thanks for the question. You made the comment that you're trying to become more penetrated in small biotech. You're at 15% now, but what is your ideal mix here? How does your strategy change when you're targeting these smaller customers? What solutions are resonating with them? Thanks.
Sure. Lot of questions there, Christine. Just be clear, you know, the biotech, it's about 30% of our business is in the biotech, small biotech. The capital market, what we call the small cap, we define them as those companies that spend $100 million or less annually in R&D. That's about 15% of our revenue. Just to clarify a little bit, in terms of where our business is. About a third in biotech, including those small ones, and then there's mid-size and about half of our business is in large pharma. I mean, to answer your question in terms of getting more penetration, we do see opportunities in that space.
There are a lot of companies in there, and many of them are doing very good science, so we have some real opportunities. As we move forward with them, as I think I've indicated, we vet them very carefully in terms of what we do and how we contract with them. We have that ability to do that. We're finding that we have a strong opportunity to help them develop their drugs and devices in a way that is perhaps a bit more efficient than maybe they would've done left on their own or working with somebody else. We have a strong drug development group. We can put together a plan that essentially spends their money more effectively. That's the way we like to look at it.
plans their registration programs, plans their clinical development plans, and runs their studies more effectively and more efficiently. That's the opportunity we see as we see companies, you know, wanting to spend their money more deliberately and more effectively in the space.
Great. Thank you.
Thank you. Now we're going to take our next question. Please stand by. The next question comes from the line of Patrick Donnelly from Citi. Your line is open. Please ask your question.
Hey, guys. Thanks for taking the questions. Steve, maybe just one on the setup. I mean, you guys have talked about the backdrop generally still being pretty solid, maybe a little bit on the biotech side. I know intra-quarter, you talked a little bit about the 2023 setup, kind of saying, you know, funding remains muted, potentially in a scenario next year is maybe a little more mid-single% versus high single%. Can you just talk about, I guess, what you're seeing currently, what plays into what that scenario could look like into next year on the growth side?
On the growth for ICON, Patrick, you looking for?
Yes. Yeah, absolutely.
Yeah. Okay. I mean, we are, you know, at the moment we're standing behind our plan for, you know, the 7%-9% on a longer term basis. We have, you know, a plan to get to $10 billion by 2025. We don't see anything in the current environment that would stop us moving in that direction and going that. We've talked about high single digits as we get into the back end of this year, and that's the sort of number we should be thinking about or we are thinking about as we go through in the next couple of years. The funding environment, there's a lot of talk about it, and clearly it's attenuated and come down over the last few quarters.
If you look at the absolute levels, they're still in a from a historical norm basis, still in a pretty good place. You probably got to go back, you know, three, four, five years to be there. We've had an extraordinary period really over the last few years. Really if you look at it on a sort of average basis over the last 10 or 15, you know, the amount of money that's out there is still pretty solid. We see plenty of opportunity in that space. We're still seeing you know, RFPs and opportunities and engaging with customers.
We had talked to a customer recently, just yesterday, who had raised well over $100 million to, you know, to prosecute three of their phase IIIs, which we're helping them with. There is money out there for good science. We feel that we can help our customers drive that, and that can continue to fuel obviously our growth expectations, which remain as we've outlined previously.
That's helpful. Brendan, maybe one for you just on kind of the margin guidance and then the synergies as well.
Mm-hmm.
Obviously the incrementals jump up a bit in the second half here. Can you just talk about, I guess, the confidence level as you work your way through this year in terms of kind of maintaining that earnings guide? Obviously, the synergy, you know, pull forward helps a bit. Then on the synergies, it doesn't seem like a true cost pull forward given that obviously next year you're kind of increasing the numbers as well. Can you just talk about what's trending better there and how you're able to kind of deliver the savings this year and then obviously next year as well?
Sure. Yeah, no. I think in the second half, yeah, I mean, we were, as Steve mentioned in his comments, we're very pleased with our margin progression even in Q2. I think we're set up well for our margin progression as we get into Q3, Q4. We need to continue to execute to our plan, obviously. We need to continue to be efficient as an organization. We've got a big plan around our synergies as we've spoken about before, and I'll come back to that in a moment. Certainly we need to continue to execute on that.
As you saw with the 25 additional on the realized in 2022, up from 75 in Q1, we do feel like we're moving at a good pace through that ambition of getting to the 150. We think given our strong and solid, particularly I'm very happy with the gross margin profile in the current quarter. That comes from a good mix of very good solid underlying business from a direct fee perspective and good efficient use of our projects and our staff as we go through the second quarter as well.
The pipeline remains good and solid. We're working on more business that we'll be able to continue to deliver to that kind of margin profile in the second half of the year. As I said, we've got good visibility on our synergies. I think on the synergies specifically, just come back to that, you know, I think we're pretty good cost managers, as you guys know from many years of interaction. We were always going to look to drive harder on the timing, certainly, of our synergies. I'm very pleased that we've now realized, and will realize, $100 million, and we feel we have good visibility to that during the course of 2022.
Now obviously we've got the external announced target of $150 million there, and we feel that we will be able to totally implement that so that we're in good nick to deliver those kind of savings from 2024 onwards. Yeah, we're making good progress there. We've been running ahead of the curve, obviously, on this one. We'll try to continue to do that. Right now we're happy with the progress we've made. If we feel like we're in a better position as we go on through the course of the year, of course, we'll update you guys as we go through that.
Helpful. Thank you.
Thank you. Now we're going to take our next question. Please stand by. The next question comes to line of Sandy Draper from Guggenheim. Your line is open. Please ask your question.
Thanks very much. If I can maybe speak into just housekeeping and then in one sort of bigger picture. On the housekeeping, just to make sure I have it correctly, Brendan, so it looks, sounds like the total FX headwind is now 2.2%-2.4%. That's assuming it was 1% before and is now 1.20%-1.40%. The other housekeeping is I wanna make sure the $60 million-$80 million incremental revenue headwind, that's China and Russia, Ukraine, or just one of those? Or I just wanna make sure I get that. The strategic question for probably Steve is the strategic opportunities that are coming up in the pipeline, is that a notable increase compared to the past? Is there different things driving it?
You know, is it people looking to replace other vendors, build strategic for the first time? Just any additional commentary there would be great. Thanks for letting me speak in those questions.
I'll take the housekeeping one first, Sandy. I think the best way to maybe think about this is, we moved the midpoint of our guidance by about $160 million, as you'll be able to quickly identify once you've had a chance to look at the math. We said obviously on the call there, $120-$140 of that is foreign exchange headwind. I think that does tie in more or less to the numbers you're talking about there in percentage terms. Obviously the remainder of the $160 then is in relation to the other kind of macroeconomic environment issues that we talked about, which is a mix of Ukraine, Russia and China.
Albeit we call it the fact that Russia-Ukraine on its own would probably be a bigger quantum, and I think Steve mentioned up to $80 million. Yeah, again, you can see the fact that we're talking about still continuing to offset some of that headwind in our numbers. I think that probably gives you a kind of an idea of what the component parts are.
In terms of the strategic question, Sandy, you know, the opportunities really fall into a number of different buckets. In some cases we are, you know, in discussions of adding on to for a customer. In some cases it's replacing, in others it's expanding, or there's a refresh happening. In many cases that's the case. These things tend to come up every three to four years, and we're now, you know, very much a player in that market. We've been able to come into those discussions where perhaps in the past as either individual organization, that wouldn't have been the case. Interestingly, they're not just happening in the large pharma space, although that tends to be the predominant. It's in some of the mid pharma space as well.
The fact that we have both functional and full service capabilities and of course landed is also very important because there are a number of customers who wanna talk to us about these sort of hybrid models, some functional areas, but a full service component. We feel we're well positioned from a service offering point of view to be a part of these strategic discussions and these strategic partnerships. You know, we're pleased with where they go. They don't, you know, they take a little bit of time to come on board. You know that yourself. We do feel we're in a good place, you know, with a number of these discussions with a view to longer term growth for our company.
Great. Thanks.
Thank you. Now we're going to take our next question. Please stand by. The next question comes to line of Eric Coldwell from Baird. Your line is open. Please ask your question.
Thanks, good morning. I wanted to hit on this margin, you know, expansion improvement. It's very impressive. Obviously, you do have some cost actions and PRA synergies, but it sounds like there's also maybe a acceleration in service revenue above what you possibly anticipated in the past. You know, you mentioned the cancellations, which were actually below my model, but you know, maybe ticked up a little versus the recent average. You said those were related to COVID vaccine studies. I'm wondering if some of that might have been pass-through revenues such that just the optics on the margin are benefiting from lower pass-throughs than perhaps you anticipated to start the year. I'll start with that question and I have one more follow-up. Thanks.
Yeah, Eric, it's Brendan here. I might give a crack at this.
You're quite right, actually, although it's not a COVID vaccine, it's a vaccine study, but it's a down scope. You're right. On vaccine studies, there's always the biggest pass-through element, and as you know, we always talk of our business wins and our revenue inclusive of pass-through. There absolutely is an optic there that probably plays against us a little bit in the quarter, from the cancellation quantum perspective. That's quite correct. We've been really happy with our I mean, you know, we called it out on the call in terms of our direct fee revenue growth, you know, ex-COVID, on a constant currency basis. You know, it's 16% up year-over-year on an ASC 606 basis. Yeah, just to clarify that point.
It's Kate. Kate's giving me a little hint here to make sure I put that in. You know, that's been strong performance. You know, it comes back to, I suppose, the dilemma we've been talking about over the course of this year, and that is that we, you know, we came into the year with good visibility of nice, strong, you know, as a mix of business in terms of our non-COVID business. That's been playing through well. Obviously, that step down in the proportional margin, or should I say the proportional pass-through, is very positive from a margin expansion perspective as we go through the course of the year. I think it's in line probably with our expectations to this point. I'm, as I said, very pleased with gross margin.
I made that comment earlier on. We are seeing good utilization of our business. I suppose it's a couple of things. It's strong revenue as anticipated with a better mix, COVID, non-COVID, and then really good operational delivery from an efficiency of headcount perspective, and utilization of that headcount as we went through the first half of the year. Yeah, I wouldn't say we're out of line with our expectations at this stage, but certainly happy with where we're progressing.
Okay, great. On my other question, it's about hiring. You have accelerated your headcount addition, net headcount addition again this quarter, very big number. Can you talk a little bit about the labor environment, the recruiting situation, turnover? Just a broad stroke on what you're seeing on the human capital side of the business. Thanks very much.
Sure, Eric. Steve, maybe I'll take that one. Certainly, we have you know, we continue to hire you know, pretty aggressively. We have a lot of work to do, and we're bringing people in at a you know, at a pretty rapid rate. You know, in terms of the labor market itself, it's challenging. You know, there are certainly some you know, the costs of bringing people in are significant. They're certainly more significant than they were a year or two ago. But it's not crazy, and it's certainly, I think, we've seen perhaps over the last month or two, even in a relatively short period, but some attenuation of that.
The labor market seems to be modifying a little bit, and I think we're certainly able to meet our goals in terms of recruitment and the costs of that recruitment. You know, it's a little early, but my impression is that it's becoming easier. In other words, the costs are not as skyrocketing perhaps as much as they were, say, 12 months ago. I think from that point of view, our recruitment is in good shape. Our retention certainly improved over the last quarter or so. We've moved that up several hundred basis points, if that's the right way to put it. Well over 80% now and making good progress on a month-by-month, quarter-by-quarter basis.
Again, we're doing a number of things in terms of training programs, development opportunities for people, you know, making sure we have retention programs in place. We feel that the labor market is, as I say, modifying a little bit in a positive direction for us. We're also able to. You know, I'm sure you're interested in that from a margin perspective. The pricing negotiations with customers have been constructive.
Mm-hmm
I would say.
Yep.
Probably more constructive than any time I've seen in the industry over the last, you know, whatever it is, 25 years. They really do understand that we, you know, it's always in our best interest to be able to pay people market salaries and to retain people. I think our customers are on board with that, and the partnership angles that we have with our customers really help those sort of discussions. We can have very honest discussions. We get independent surveys. We have good data now available on what those salaries are, and that does help us to have those pricing discussions with customers.
All in all, I would say the labor market is improving, you know, overall from whether it be from a recruitment and a retention point of view.
Thank you very much.
Thank you. Now we're going to take our next question. Please stand by. The next question comes from the line of Casey Woodring from J.P. Morgan. Your line is open. Please ask your question.
Hi, guys. Thanks for the question. Just can you comment on the DSO in the quarter? It looks like it increased 17% sequentially to 41%. You know, I noticed that there was no reiteration of the prior DSO guide for the full year, which had been 25-35 days. Just wondering if you have any updated expectations there, and if there's any concern around cash balances on the small side that's driving that number up.
Hi, Casey. I'll take that one. It's Brendan here. Listen, it did go out on us a bit during the course of the quarter. We certainly want to see it back below 40% as we think about the back end of the year and into Q4. We are doing a lot of change management in our finance organization at the moment. That's both in terms of location of heads, but also the systems that we're using. So there was a lot of focus on that. I think that the upshot of that is a little bit of a lack of focus on DSO, and we need to right that, quite frankly, in the second half of the year.
It doesn't give me any great pause for thought. There was nothing in our customer base that worries me from a aging perspective or a debtor book, or any other elements. I didn't think there was any particular, you know, cohort of our debtors that were more troubled than anywhere else. Still a very, very solid cash collections profile. Wouldn't revise any of that. Expect that as we go through the course of the year. Again, I expect that to flow into cash nicely. We always see a bit of a dip in our second quarter in terms of cash from operations, but I would expect that to pick up again in Q3 and Q4. No, a little bit more work to be done, certainly.
A lot of plates spinning here in the finance organization at the moment. We're making good progress, generally speaking, and we would like to see this come back under 40% by the time we get to the end of the year.
Got it. That's helpful. Just on the SMidCap RFP flow, you said it was down a bit year-over-year. One of your smaller peers the other day talked about how its RFP flow from SMid biotech is maybe artificially inflated during this time, just as a lot of these customers are fishing for price between CROs. Do you believe this is true for your SMidCap customer base? You know, is that kind of RFP flow you called out maybe a little higher than normal given you know some of those dynamics? Thank you.
Casey, we're not seeing that. As I indicated with, you know, the RFPs we get in, there are basically three categories. You win some, you lose some, and some get canceled. We're not seeing. In other words, the ones that get canceled tend to be the ones that have been submitted for, you know, sort of pricing discussions or at least some sort of pricing indication. They never had really any intention of outsourcing. That number hasn't gone up. That's in the, you know, as I said, it's in the mid-teens fairly consistently across the business. We haven't seen that go up over the last quarter or not. I don't believe that our biotech customers are, you know, floating, you know, throwing stuff out there that's not valid in general.
You know, 85% of it, you know, either moves towards an award, either it's a successful award or an unsuccessful award. I don't see any evidence of them just putting stuff out there for the sake of it.
Casey, may I just confirm, have you finished with your questions?
Yes, that was great. Thank you.
Thank you. Now we're going to take our next question. Please stand by. The next question comes from line of Justin Bowers from Deutsche Bank. Your line is open. Please ask your question.
Hi, good afternoon, everyone. Just following up on kind of the backlog and the awards. Has there been any shift in kind of what customers are seeking, the type of solutions, you know, over the last couple quarters, whether it's, you know, full service FSP mix, more DCT, et cetera? Can you help us think through how, in the context of full service clinical, if something were to enter the backlog now, when that would actually start to burn and show up in revenue?
Okay, Justin, to answer the first part of your question, shift in terms of solutions, I mean, we're certainly seeing an increased demand for these more decentralized components within our clinical trials. We feel we're in a good place as we develop our decentralized platform and our services around that decentralized platform that we're able to provide, if not the whole solution, because there are still not very many fully decentralized trials, but we have all of the components. I think that's probably a shift that's happened really as we come out of the pandemic. The more risk-based monitoring approach seems to be more in play. Our home healthcare services have been in demand. Our Accellacare sites. We're moving on with the e-consent sort of areas.
that would be a, I would say, a trend. In terms of FSP versus full service, I don't think we see any particular move either way. As I mentioned in terms of our partnership discussions, many of the companies who are looking to partner with us want to have the option of a functional service provider as well as a full service provider. Some part of their portfolio, they may do full service. Other parts of their portfolio, or their functions they wanna have in-house or they wanna have a functional sort of overseer or provided together. We're able to provide both of those sort of areas of the business. That's, I think, very positive for us and puts us in a good position around those partnership discussions.
In terms of backlog and burn, you know, the timing in terms of that can vary. If you get a rescue project, it could be, you know, you get it Friday and you start Monday. On the other hand, we're pretty careful about what goes into our backlog. We don't put projects into our backlog that have a first patient in beyond, I think it's about 9-12 months. We also don't put it in if there's a go-no-go decision to be made in a program. What goes into our backlog is fairly conservatively managed, I would say.
You know, to give you some sort of indication, I would say on average, it's probably 3-6 months from award till we start work. It can be a little faster than that at times. It can be a little longer than that at times. I would say that's the sort of ballpark number.
Thank you. That's helpful. Just one follow-up on that. It sounds like you're expecting growth ex-COVID to accelerate over the next few quarters, and how much of the backlog still has COVID in it, roughly?
We expect our COVID revenues to be around about the 5%, maybe a little less as in the second half of the year. There's certainly still some COVID work in there. No question about that in the backlog. In terms of acceleration, I mean, I think 16% is a pretty good rate of growth ex-COVID, Justin. You know, I'm not sure I'm gonna sit here and tell you that we're gonna be growing faster than 16%. That's the number that we've been able to, you know, to get through excluding COVID on a constant currency basis. And, you know.
I'm not sure I see as fast, as I say, faster than that, but we certainly see our non-COVID revenue continuing to grow, and we certainly see it, as we've already said, continuing to provide us with opportunities for continuing to improve our margins. Yeah.
Justin, just on the percentage of COVID work in backlog, it is similar to that level that Steve quoted around that percentage of revenue that we expect, which is in and around 5%. So that's the expectation as we go through the second part of the year. Just as a reminder that, you know, Q2 last year was certainly our highest percentage of revenue in terms of COVID work last year. So that was our toughest comp.
Yeah.
Yep. Appreciate all the questions. Thank you.
Thank you. Now we are going to take our next question. Please stand by. The next question comes to line of David Windley from Jefferies. Your line is open. Please ask your question.
Hi. Good morning and good afternoon. Thank you for taking my question. I wanted to drill in a little bit on the emphasis on direct fee growth, make sure I kind of understand, but it seems to both incorporate parts of what Eric asked in the change and maybe down scoping of pass-through elements that would then, you know, modestly shift mix toward direct fee. Then you also are talking about DCT elements, kind of highlighted in what solutions are being demanded. I just wanted to better understand how the mix of demand of backlog bookings are coming through as it relates to direct fee versus pass-through and how that's evolving, and if you feel like your kind of forward expectations of that mix are appropriately, you know, set. Thanks.
Yeah. I might take a crack at this one. It's Brendan here. I suppose really what that makes then I wouldn't like to think we were very downplaying, you know, pass through. I mean, obviously pass through is a big element of our revenue, and will continue to be. It's just obviously we've come through a very extraordinary period where in the first half of last year was completely outsized. I think the way to think about it though is that we are definitely coming back to a period now where pass through represents no more or less than it did before COVID. You know, we're probably back to that proportionality of both business wins and revenue as we go forward. Kate made a point, we're about 5% of backlog on those big COVID trials.
Vaccine mix is an element of that, but obviously we're not seeing the same kind of super-sized studies and outsized studies, if you like, that we saw during the COVID era. That's certainly something to bear in mind. You know, of course, the mix of revenue is important, and the margin profile is changing quite a bit from a margin perspective, but it's because we're seeing that COVID boost really now lagging out of the numbers and really seeing that margin profile move up. As I said, the pass-through elements will probably be where they were back in 2019 as we think about the back half of the year.
Okay.
I think Dave, just to add to your second part of the question around DCTs and different, you know, risk-based, I think that will fuel our margins. But I do think that's more in the longer term. I think it. I wouldn't want to sit here and tell you that that's a real source of driving the margin in the relatively short term. That's more of a longer term play.
Okay. Brendan, on the SG&A comments through the second half of the year, you said kind of dollars remaining relatively constant, you know, in a positive way, kind of back to your old ways. I'm wondering with a $50 million kind of incremental synergy realization in 2023, if you know, continuing on back to the old ways, if that can, if that kind of stability in dollars of SG&A can continue beyond 2022, it looks like that could, you know, or maybe the $50 million doesn't completely manifest in the SG&A line. But I'm just curious about, you know, how you might continue to scale the SG&A ratio as you did through the mid-2010s.
Yeah, I mean, like, you know, to be honest, David, every target will become the floor. You know what I mean? Every ceiling will become the floor. As we get to our target, and you know we're a conservative bunch, we don't generally talk about targets we don't think we can hit them. We also don't talk about the next target before we do the first one. I do think it's fair to say we, with good visibility to do that, I think that will continue our ability to have significant leverage on our SG&A base as we go through 2023. Yeah, I think it's probably within our ambition to continue to leverage that SG&A.
Even as I said it back when we talked about it in February when we were on our analyst day, we talked about the path to 21%. We do see a big chunk of that coming from continued SG&A leverage, and that probably means going down to in the ballpark of 9%-8% on SG&A over time. I think that's certainly within our ambition and certainly within our scope of how we're thinking about our SG&A. Will that deliver absolute dollar for dollar flat into 2023 and 2024? I think that's one we'll have to wait and see, Dave, at this point. Certainly we deal with a lot of ambition about continued leverage.
Got it. If I can ask just one more. Steve, I appreciate your comments on your own labor force, retention, recruiting, et cetera. Because ICON owns its Accellacare network, I would think that you have somewhat of a unique, maybe a more boots on the ground view into the site level. We are hearing increasing feedback that the labor stress at the site level is perhaps still rising, you know, kind of consistent with what we hear out of the healthcare system in general. I wondered if you could comment on that and how that might or might not be affecting the throughput for, you know, kinda your supply chain and the throughput for trials at the site level.
Yeah. Yeah, it's a really good point, Dave. You're absolutely right. We are seeing some challenges at the site level, particularly in terms of, you know, labor and availability of labor. We feel we're in a better place than most on that front because we have our Accellacare sites, and of course, they're staffed in most cases by our own people or supported by our own people. We have more of an ability to, you know, to coordinate and manage that. We're finding the Accellacare sites are starting to disproportionately perform. They already have been, but their performance has been even more enhanced. I think part of it is because of the stability of the labor force that we're able to provide.
One of the other opportunities we believe we have with our home healthcare and the Accellacare resources is actually deploying some of that resource to some of these sites that may not be within our network, but obviously need support. There's a business opportunity there that we are actively pursuing and feel we can get some benefit from as well because of those resources we have. As I say, in the home healthcare, they don't go to obviously the patient's home, they go to the site and help the site. There is some opportunity there, but it is a challenge. I think right across the industry, the sites are under pressure. A lot of the recruiting that we and many of our brethren have been doing is from sites.
Study site coordinators, study nurses make very good CRAs in many cases. The sites are under some pressure, and it's something that, as I say, represents a challenge but also a significant opportunity for us going forward.
I appreciate the answers. Thank you very much.
Yeah.
Thank you. Now we're going to take our next question. Please stand by. The next question comes from the line of Luke Sergott from Barclays. Your line is open. Please ask your question.
Hi, this is Salem on for Luke. We just had a question on COVID headwinds in the second half. Do you have any color there?
I think, Salem, as we just talked about there a moment ago. I think most of the headwind on the year-over-year comparative was always gonna be in the first half of the year. You'll see it. I mean, it's not gone away, obviously, entirely in the second half of the year, but the most significant hill we had to climb was in Q2. There'll be an element of that in Q3, Q4, but not to the same extent that we've seen in Q1, Q2.
Gotcha. Sorry for the redundant question. We have another question on the pricing environment on RFPs. Could you guys give us any color there as well?
Oh, you know, I don't think we see any major changes on the pricing environment. As I think I alluded to or I spoke to previously, in terms of pricing from a rate point of view, customers have been constructive in their conversations we've had with them around increases, and the ability for us to you know to move our rates up in a manner and in an amount that's in line with not just inflation, but with the current market, and the current market for our staff and the challenges we have there. You know, I think I mean, pricing discussions are always you know a challenge within our industry. It's a very competitive industry. That's how it should be.
We don't see any particular challenge or any particular issue that's driving more of a challenge in that space at the moment. You know, it's always competitive, continues to be competitive, and I don't expect it's gonna change anytime soon.
That's helpful. Thank you.
Thank you. We are now going to take our next question. Please stand by. The last question comes to line of Derik De Bruin from Bank of America. The line is open. Please ask your question.
Hi. Good morning or good afternoon. This is John on for Derik De Bruin. On net leverage, you've gone from targeting sub 3 times to just, it was previously your aspirational 2.5 times EBITDA. Now you're there, you're targeting that 2.5 times as you continue to pay down the debt. Now do you continue to make progress in bringing your leverage down? Where are you in terms of pursuing share repurchases? Could you talk about your M&A pipeline as well and how the market is? Are you starting to have more inbound discussions on maybe data assets, additional site networks?
Sure. From a share buyback point of view, we really are focused on share buybacks at the moment. We're laser focused on paying our debt down. As you know, the Fed raised interest rates, I think it was yesterday, wasn't it? 0.75%. We're expecting, we've modeled in further rate increases. From our point of view, with where our share price is at the moment and where our company is at the moment and what the likely scenarios are going forward, on an interest rate basis, we think that is the best use of our capital to put it into paying down the debt. We're very, as I say, very focused on doing that.
At least at the moment, there's no real thought of buying back shares. We'll, you know, obviously as we get down to under three, and we have, as Brendan and I often talk about, our aspirational target of 2.5, as we get into next year, we'll obviously start to think about that or reconsider that and be probably a bit more opportunistic on that basis. That will obviously lead also to a review of our M&A pipeline. At the moment, we're seeing, we're making such good progress on that front, but we are starting to look around the industry.
As we go through some of the macro environmental and economic challenges, you know, we think there could be opportunities for us, whether they be in the data analytics space, as you mentioned, or in the site network or in other parts of our business. We are, you know, very focused in the clinical business. We wanna continue that. We do see some opportunities around helping us to get patients into clinical trials faster and better. Those are the area we're looking at. Data analytics site and the networks around sites. Those are the areas we would consider, but we're not ready to pull the trigger on those at the moment. We're starting to scan the environment.
We're looking at what opportunities may be available in the next 12 months or so. At the moment, as I say, the real laser focus is on paying the debt down.
Great. Thank you. In 1Q, you guys talked about some supply chain challenges surrounding kit supplies. Any ongoing issues there?
No, those are pretty much resolved now, John. You know, we did have some challenges, as I alluded to, as I mentioned on the previous call. We've worked hard to get our ducks in a row on that front. We are now in a much better place on that front. That situation is resolved.
Okay. Great to hear. Thank you.
Thank you. There are no further questions, and I would like to hand the conference over to Steve Cutler for closing remarks.
Okay. Thanks, operator. Thank you everyone for joining the call today. We are pleased to have delivered another quarter of solid financial and operational performance and extend our gratitude to over 40,000 employees across the globe for their continued contributions to our mission of accelerating development of our customers' drugs and devices. Thank you all, and have a good day.