Early Results from Statewide Surgical Quality Collaborative Demonstrate Persistent Guideline Discordant Care

Document Type

Conference Proceeding

Publication Date

2-20-2026

Publication Title

Ann Surg Oncol

Keywords

blue cross blue shield, clinical practice guideline, conference abstract, controlled study, female, health care cost, hormonal therapy, hospital charge, human, invasive breast cancer, Michigan, overall survival, sentinel lymph node biopsy, surgery, total quality management, university hospital

Abstract

Since 2016, national guidelines have advised against sentinel lymph node biopsy (SLNB) in women over 70 with early-stage, hormone-receptor-positive, invasive breast cancer, citing no overall survival benefit compared to surgery and hormone therapy alone. Despite this, SLNB rates remain variable, leading to unnecessary clinical risk and healthcare costs. In 2024, the Michigan Surgical Quality Collaborative (MSQC), a Blue Cross Blue Shield-supported collaborative of 69 hospitals in Michigan, launched a quality improvement initiative to reduce SLNB rates in this population. METHODS: Using the sampled cases from the MSQC data registry, we assessed the rate of concurrent SLNB among women over 70 who underwent surgical resection for invasive breast cancer between 1/1/2024 and 5/31/2025. We determined the overall SLNB rate for the sampled population and for each hospital. We identified hospitals with highest and lowest SLNB rates and analyzed basic characteristics of each group. Chi-squared, Fisher's Exact, and Kruskal-Wallis tests were used to assess for statistical significance. RESULTS: 1,944 cases were sampled from 62 hospitals. 33% of women undergoing surgery for invasive breast cancer had concurrent SLNB. Individual hospital rates varied from 0% to 8 1% (Figure). Hospitals that performed fewer than 10 cases total (n=8) were excluded from subsequent analyses. Among the remaining hospitals, 11% (n=6) had SLNB rates above 70%. Of these, 100% were non-academic hospitals, 83% had < 300 beds, 17% had 300-499 beds, and between 1 and 4 (mean 2.5) unique surgeons were captured in sampled cases. 28% of hospitals (n=15) had SLNB rates below 20%. Of these, 87% were non-academic, 53% had < 300 beds, 33% had 300-499 beds, 13% had >500 beds and between 1 and 6 (mean 3) unique surgeons were captured in sampled cases. Between-group differences were not statistically significant. CONCLUSIONS: Nearly a decade after the Choosing Wisely campaign, SLNB rates in older women with low-risk cancers have declined, yet statewide variation persists. Notably, 11 % of hospitals in our sample demonstrate minimal penetration of this recommendation with rates of SLNB greater than 70%. Further work is needed to understand why there is a lack of recommendation adoption at specific hospitals and to ensure guideline concordant care across the population. Disclosure: Blue Cross Blue Shield of Michigan and MSQC work collaboratively, however, the opinions, beliefs and viewpoints expressed by the author do not reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees.

Volume

33

Issue

1

First Page

S70

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