The role of urgent care centers in headache management: a quality improvement project

Background Patients with headache often seek urgent medical care to treat pain and associated symptoms that do not respond to therapeutic options at home. Urgent Cares (UCs) may be suitable for the evaluation and treatment of such patients but there is little data on how headache is evaluated in UC settings and what types of treatments are available. We conducted a study to evaluate the types of care available for patients with headache presenting to UCs. Design Cross-Sectional. Methods Headache specialists across the United States contacted UCs to collect data on a questionnaire. Questions asked about UC staffing (e.g. number and backgrounds of staff, hours of operation), average length of UC visits for headache, treatments and tests available for patients presenting with headache, and disposition including to the ED. Results Data from 10 UC programs comprised of 61 individual UC sites revealed: The vast majority (8/10; 80%) had diagnostic testing onsite for headache evaluation. A small majority (6/10; 60%) had the American Headache Society recommended intravenous medications for acute migraine available. Half (5/10) had a headache protocol in place. The majority (6/10; 60%) had no follow up policy after UC discharge. Conclusions UCs have the potential to provide expedited care for patients presenting for evaluation and treatment of headache. However, considerable variability exists amongst UCs in their abilities to manage headaches. This study reveals many opportunities for future research including the development of protocols and professional partnerships to help guide the evaluation, triage, and treatment of patients with headache in UC settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07457-2.


Background
Migraine, a chronic disabling condition characterized by acute attacks of head pain and associated symptoms, accounts for a substantial portion of the 4-5 million emergency department (ED) visits per year for headache [1,2]. Long wait times, loud noises and bright lights, overuse of neuro-imaging, and suboptimal treatment of acute migraine attacks with medications such as opioids, make the ED less than ideal for patients with migraine [3]. Headache specialists, in turn, have employed infusion centers as a mechanism to prevent ED visits. However, a recent study of headache infusion centers showed that few centers offer infusions outside business hours [4]. Moreover, headache providers cited numerous barriers to maintaining these centers [4].
An alternative solution for treating patients with refractory migraine may be the use of urgent care (UC) facilities, sometimes known as Walk-in Clinics or Express Care clinics. Urgent Care Services are defined by the Centers for Medicare and Medicaid Services (CMS) as services furnished within 12 h in order to avoid the likely Open Access *Correspondence: minenmd@gmail.com 1 Departments of Neurology and Population Health, NYU Langone Health, 222 East 41st Street, 9th floor, New York, NY 10017, USA Full list of author information is available at the end of the article onset of an emergency medical condition. UC facilities location is distinct from a hospital emergency room, an office, or a clinic, and purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention [5,6]. Currently, there are over 8000 UC facilities in the United States, with a 58% UC growth rate from 2013 to 2019 [7,8]. UC facilities are designed to manage unplanned visits for lower acuity conditions [9]. They are widely available and offer same-day and walk-in appointments after hours and on weekends, an ideal circumstance for the needs of patients with migraine. UC facilities result in cost savings by decreasing unnecessary ED visits and a concomitant increase in hospitalizations [10]. Statistics demonstrate that 14-27% of ED visits could be handled in an alternative medical setting like an UC facility [9]. One financial evaluation showed that a switch of these cases to UC facilities could result in savings of up to $4 billion per year [10].
While two recent studies examined UCs and migraine in New York City [11,12], they only looked at the number of UC visits for headache and/or migraine in an 8-month period (over 10,000) [12] and migraine management in UC facilities that were part of one urban academic medical center. In the latter study, we learned that there are ways UC facilities might be optimized to treat people with migraine, i.e. stocking migraine specific medications like sumatriptan, having pain assessments for those complaining of pain so that providers can assess whether pain decreases on discharge, considering the use of headache protocols and tools like the Migraine Action Plan [13] which can guide providers as to which medications to use, and ensuring that medications for various migraine symptoms (i.e. nausea/vomiting) are prescribed when needed upon discharge. In this study, we seek to assess UC facilities' headache management practices at multiple sites across the US, how they compare to previously studied UC facilities, and to identify potential opportunities to improve headache care in the UC setting.

Methods
We submitted to the Institutional Review Board (IRB) of New York University Langone Health where it was deemed a quality improvement study and thus IRB approval was not needed. In an effort to compare other UC facilities to the one published study on UC for migraine [11] and to better understand how UC facilities might serve the headache population, an email invitation was sent to headache specialists who are members of the American Headache Society Refractory/Inpatient/ Emergency Care Special Interest Section to (1) ask them what questions they would like to ask on a survey and (2) whether they would like to help collect data for the study.
The survey was then written using an iterative approach over email based on the findings of the prior study [11] to understand the operations specific to their local UC facilities with specific questions targeted to headache practice and treatment. Facilities that fulfilled the CMS definition for urgent care services or facilities were selected by convenience sampling. Local UC centers were either known to authors, located via web searches or health provider recommendations. The full questionnaire can be found in the Additional file 1: Appendix.
These authors then contacted their local UC facilities by phone and/or email and collected the data. The eight headache specialists on the author panel obtained the information in the following ways: 3 headache specialists (AE, AP, FK) emailed the survey questions and headache specialists (AA, AE, LC, MB, MTM, NS) asked the questions by phone. In a few cases, (MTM) they received emails confirming some of the responses. The headache specialists communicated with a range of professionals who could provide the necessary information. Three headache specialists (AA, FA, MTM) contacted the medical directors of the urgent care centers, one spoke with a Clinical Associate Professor of Primary Care (AP), one (AE) spoke with the Clinical Nurse Manager and sent an email with follow-up questions to the medical director, another spoke with a NP (LC) and then two others (MB, NS) reported speaking with a range of people, depending on the availability and knowledge: providers (most often advanced practice provider), medical assistant, receptionist (most commonly), practice manager, other staff.
Of note, for the purposes of this study, a UC facility could be defined as an "urgent care, " "express care, " or "walk in" facility.
The data obtained from the local UC facilities was recorded in Redcap [14] and descriptive statistics were conducted in Excel. We report means, medians, percentages, and standard deviations.

Results
Between June 2020 and July 2020, a total of eight headache specialists contacted their local UC programs and collected and entered the data for 10 different UC programs in the US. The 10 UC programs comprised 61 individual UC facilities. Within each UC program, there was a mean of 6 UC sites and a median of 2 UC sites. The UC programs were scattered around the country (See Fig. 1: Map). Of the 61 individual UC sites reported, the majority (56%, 34/61) were part of an institution and most of the remaining (41%, 25/61) were free standing sites. Two sites (3%, 2/61) were identified as both freestanding and part of an institution. As noted in Table 1, an average of 41,621.6 total visits per year for all conditions were reported at the surveyed UC programs. The average reported number of physicians, nurse practitioners, and physician assistants per UC program was 12.8, 3.1, and 1.8 respectively.
For the remainder of the Results section (including the tables), all reported data are based on the 10 UC programs in aggregate.
Five out of 10 UC programs (50%) mentioned that there was a headache or migraine protocol in place at the respective UC sites. The majority (60%, 6/10) reported that there was no policy in place to ensure that the patient would follow up with their primary care provider (PCP), neurologist, or headache specialist. One of the programs that had a headache treatment protocol in place did not have a follow up policy. Only two programs reported that > 1% patients have a disposition to the ED. The remainder said "none" when asked about patients with headache being referred to the ED from the UC. Table 5 reports the assessments/protocol used for pain and headache management. A total of 8 UC programs (80%, 8/10) complete pain checks regularly and reported having pain assessments at their corresponding UC program to evaluate and manage patients with headaches. Onsite diagnostic test(s) for patients with headache disorders are provided at 8 (80%, 8/10) of UC programs. Out of the 9 programs that provided the average length of stay for patients with headache, 3 programs (30%, 3/10) reported that patients stay less than 1 h, 40%, (4/10) reported 1 to 2 h, and 20% (2/10) reported more than 2 h.

Discussion
In this study, we noted several key findings: (1) As expected, UC facility hours are typically longer than standard outpatient office visit hours, with the vast majority open in the evenings and a significant minority open on weekends, and lengths of stay are typically quite short (7/9 reporting 2 h or less); (2) The majority of the UC facilities surveyed offer intravenous treatments, Table 1 Characteristics of Surveyed Urgent Care Facilities a This is the average number of locations provided per respondent b Respondents provided more than one UC location in the area where their US is located but only provided the specific area for the UC they provided an address for c 5 out of 10 respondents answered that there were no nurse practitioners at the site listed Long hours of operating at UCs provide a person with migraine with the option to seek care outside of the emergency department after-hours. In addition to the cost benefits outlined above, urgent care settings are quieter and less crowded, factors that are important to a patient in the midst of an intractable migraine. Furthermore, emergency department wait times tend to be longer and parking more distant, and such delays are not only inconvenient, but also delay relief from migraine. As migraine is a chronic disorder with episodic attacks, patients are likely to seek care for an intractable episode if the visit is focused, convenient, and provides quick effective relief.
The majority of the UC facilities surveyed offer intravenous treatments, with at least one of the level B recommended drugs: IV metoclopramide or IV prochlorperazine. (Currently, there are no Level A recommended medications for the acute management of migraine in the emergency setting.) Per the American Headache Society guidelines, Level B medications should be offered to patients for acute migraine treatment based on available evidence [15].
Half of those surveyed had headache treatment protocols and the majority of the UC facilities did not have follow-up protocols in place. Many did not have a protocol in place for diagnostic workup or referral to higher level care like the ED, as only 2 programs reported referral to ED. They also did not have protocols for how to best treat the patients in the UC or upon discharge. Previous studies have shown that patients with migraine visiting UC are not receiving treatment according to the highest level Weekend hours N = 10 Open one weekend day 30% (3) Open two weekend days 70% (7) Reported average length of stay for migraine and headache patients a N = 10  [11]. In addition, the route of administration is critical, with oral medications often failing to address the headache at home, parenteral treatments may be warranted. However, only 3 out of 10 medications reportedly offered at UCs in the survey were available by parenteral route. The following adjustments may help to improve diagnosis, promote individualized care, and increase use of medications of the highest level of evidence − 1) use of a validated screening tests such as ID Migraine to assist with diagnosis of migraine, 2) widespread use of the Migraine Action Plan [13,16] would allow the patient's outpatient headache provider to identify a personalized approach to acute headache management in the UC setting, 3) employing an algorithm or protocol for headache management within and upon discharge from UC. An example of such algorithms includes those used in the ED which have helped to reduce the use of opiates in that setting [17]. Migraine infusion protocols, if put in place, may allow for better utilization of existing resources at urgent care clinics. This would include expansion of other therapies felt to benefit migraine, including, but not limited to: fluids, ketorolac, magnesium sulfate, valproic acid, and corticosteroids [18]. The UCs had opioids, and use of protocols may limit use of opioids for headache management. UC facilities serve as an emergency bridge to provide a temporary care between the patient and primary neurologist or headache expert. Patients should return to their outpatient provider(s) for continuity of care as soon as possible for optimization of both preventive and abortive treatment. A post discharge satisfaction survey from UC may also be helpful to further improve care.

Future work in urgent care
As stated in the prior paper on UC visits for headache in NYC, regulation or standardization of UC facilities varies across states, so we sought to better understand how urgent care centers outside of NYC operate and might manage headache/migraine. As this is a newly expanding area with potential for headache management, there are several areas for potential study (See Table 6).

Strengths
This is the first study examining how urgent care centers in various parts of the country may be used for headache/ migraine and provides a glimpse into how they may or may not have the ability to offer intravenous medications, have certain medications in stock, or have protocols already in place for headache.

Average number of medications per UC program
the analysis. Future studies may consider prospective data collection to limit the impact of these biases. During the assessment of treatment protocols we did not explore the use of distinct protocols for types of acute headaches (for example: migraine and nonmigraine common primary headache disorders) We did not examine provider level data or patient level data to examine whether there were transfers to EDs, the reasons for the transfers, etc. Patient level data, (e.g. clinical outcomes, demographics, etc.) of those treated for headache disorders in UCs may enrich our understanding of UC role in the treatment of headache disorders and help to examine impact of healthcare utilizations and costs. We also did not obtain volume data for the UC sites. Patient volume data may inform the systematic role and impact of UC on headache care in the US. Our work is solely a glimpse into considerations for how the headache community might consider  Educating UC Providers -In terms of targeting the specific providers who are most likely to come work in an UC facility, research has shown that most facilities (95.8%) have physicians on staff, and family medicine is the most common specialty (present at about three quarters of the centers) [17].
-Other specialties sometimes staffing them include emergency medicine, internal medicine, and pediatrics. About half also have advanced practice providers (NPs and PAs).
-Thus, there is a continuing need for headache education among primary care and emergency physicians, physician assistants, and nurse practitioners. Given its population prevalence and associated disability, headache is inadequately covered in both emergency medicine and primary care residency curricula. Post-residency, management of headache should be a frequent topic of grand rounds and conference-based educational programs.
-Initiatives similar to the American Headache Society First Contact-Primary Care Initiative which educated PCPs about migraine [18] might be expanded to include urgent care providers.
-The American Academy of Pain Medicine, through its Headache Special Interest Section and its primary care migraine guidelines initiatives, might also help with this effort.
Partnerships with Academic Medical Centers/Neurology Departments/ Headache Centers -There has been a move toward UC facilities partnering with academic healthcare systems as a way of bringing in more patients to the healthcare systems. This has occurred throughout New York City [19,20].
-These numerous partnerships between UC facilities and big academic health systems can lend themselves to not only UC facilities referring patients appropriate for specialist care, but to partnerships in which neurologists and headache specialists might use these UC facilities to provide acute care e.g. infusion treatments for their headache patients rather than setting up headache specific infusion centers that might require significant staffing needs and/or sending their patients to the ED for such care. This might reduce headache ED repeat visits which have been found to be predominantly due to headache-related acute care [21]. In addition, whereas a prior study found that a substantial number of headache specialists are dissatisfied with the care their patients receive in the ED, in part because they felt that there was little communication between the ED physicians and the primary headache providers [22], such partnerships between UC facilities and neurologists/headache specialists might improve communication between providers in these different settings.
Educating Patients about the Option to Seek Acute Migraine Treatment in UC Facilities -Future work might educate patients about the difference between care provided at the UC verses the ED, providing a list of nearby UCs, their working hours, resources available and when to triage ED over UC should be a standard part of office visit counseling and coordination of care and should help to off load ED burden by diverting unnecessary patient volume as the patient is more likely to listen to their established provider more than anybody else. -Headache providers might provide patients with an after-hours/weekend protocol e.g. the Migraine Action Plan [23].
-In addition to outpatient medical providers advising patients of these options, if protocols are put into place, school nurses might be able to evaluate and refer students and their families to UC facilities [24].
working with UC facilities, considerations for discussion and considerations for future research.

Conclusion
Limited access to quality care is a significant contributor to gaps in US healthcare. The limited number of clinicians with expertise in headache management, together with the limited options for acute headache management within the confines of a typical outpatient clinic (with or without infusion capabilities), forces patients to seek care in the ED. UC centers are traditionally less busy than EDs and, with their ability to provide care during extended hours, can prove to be a valuable accommodation for patients needing management of acute headaches. Patients with predictable clinical presentations and responses to previously tried abortive regimens (for example, acute migraine) may benefit the most. Our study aimed at exploring the current infrastructure and practice parameters at UC centers as it pertains to managing acute headaches in adults and the results are very informative. A larger-scale study may provide further insight in this regard, and the preparedness for UC facilities to develop headachespecific protocols and provide quality care for headache patients. While there is a need for the development of clinical guidelines and evidence-based approaches specific to UC centers to improve outcomes, we implore on the proposition to build partnerships with UC centers with the goal of providing value-driven care that is timely and effective. -Future work should examine patient decision making in deciding to visit an ED versus an UC facility for headache with a special focus on examination of race, ethnicity, and socio-economic factors. A cross sectional study of Medicare and Medicaid beneficiaries examined predictors of who were more likely to go to UC versus ED for a non-emergent health condition [13], All those examined lived within a 10-mile radius of 12 UCC locations and have had more than one visit to a UCC, emergency department, or both. The authors of that study found low utilization of the UCCs.
-Demographically, Black participants were more likely to go to the ED compared to White participants, regardless of how close the UCC was to them and the type of insurance they used [13]. The authors concluded that the Black participants felt more comfortable walking into the ED. Also, although there has been an increase in UC facilities across the US, this growth tends to distribute in locations with higher income and more insured patients [25][26][27][28].
-Patients who visit UCs may have better insurance [17] and thus better access to outpatient headache care as well.
-A study found that UC facilities may worsen the disparities within healthcare due to financial interest, especially since refusal of service is allowed if funds are not met by the patient [25]. That said, UC facilities tend to be located in areas with a high proportion of individuals from historically marginalized/non-White populations, possibly to help mitigate the disparities associated with race and ethnicity, prompting some to conclude that the decision to locate UC centers is independent of race and fully considerate of economic advantages [25].