Integrating technology into a successful apomorphine delivery program in Thailand: a 10-year journey of achievements with a five-motto concept

Abstract

Introduction: Apomorphine, a potent dopamine agonist, is a therapeutic option for patients with Parkinson's disease and motor fluctuations. However, the adoption of and adherence to this therapy have been limited by the need for complex delivery devices and specialized care as well as resource consumption, posing challenges for new physicians. Thailand is a unique example of a developing nation that has successfully implemented and continued the use of this therapy by employing cooperative technology that has dramatically enhanced apomorphine delivery services.

Methods: Establishing apomorphine delivery services requires significant resources and step-by-step solutions. We began our services by implementing various strategies in three chronological stages: the initial stage (2013-2015), intermediate stage (2016-2019), and current stage (2020-present), each presenting unique challenges. Together, we also implemented a proposed set of five mottos to strengthen our apomorphine delivery service. Using additive technology, we developed a patient registry platform that combined electronic data acquisition, video and remote monitoring using wearable sensors, and in-house mobile applications to support our service.

Results: At the initial stage, we assembled a team to enhance the efficacy and confirm the safety of apomorphine treatment in our hospital. At the intermediate stage, we expanded our apomorphine delivery services beyond just the patients at our hospital. We supported other hospitals in Thailand in setting up their own apomorphine services by educating both physicians and nurses regarding apomorphine therapy. With this educational undertaking, increased apomorphine-related knowledge among medical professionals, and a greater number of hospitals providing apomorphine services, an increasing number of patients were administered apomorphine in subsequent years. Currently, we are providing effective apomorphine delivery to improve patient outcomes and are seamlessly integrating technology into clinical practice. Incorporating integrative technologies in our apomorphine delivery program yielded positive results in data collection and support throughout patient care, in tracking patients' statuses, in the long-term use of this treatment, and in increasing medication adherence rates.

Conclusion: This perspective paper describes how technology can help provide supportive healthcare services in resource-constrained environments, such as in Thailand, offering a step-by-step approach to overcoming several limitations. The valuable insights from our 10-year journey in successfully integrating technology into apomorphine delivery services can benefit new physicians seeking to replicate our success.

Keywords: Parkinson’s disease; apomorphine; daycare service; infusion therapy; technology.

Figure 1

(A) The five mottos of achievement of our apomorphine service, which is composed of 5 components including; (1) an apomorphine expert team, (2) standard protocols for proper patient selection, (3) suitable infrastructure and facilities, (4) appropriate education and training, and (5) additive technologies to enhance patient outcomes. (B) Between 2013 and 2023, a total of 119 patients in Thailand received CSAI. Before 2019, 64 patients underwent CSAI in 10 hospitals located in 4 provinces. However, after the development of training courses for physicians and nurses since 2019, including the ‘Apomorphine Masterclass’ and the ‘Experienced Nurse Training for Apomorphine Therapy,’ we observed an increasing number of hospitals in various provinces throughout Thailand beginning to offer apomorphine services. This led to a rise in the number of patients receiving CSAI each year, despite the challenges posed by the coronavirus-2019 pandemic from 2019 to 2021, which restricted patient access to apomorphine services due to lockdown situations in Thailand.

Figure 2

(A) Depicts a series of figures illustrating both the apomorphine registry platform on the website and the in-house ChulaPD Plus application available on mobile phones and tablets. This platform serves the purpose of recording data from patients undergoing apomorphine treatment in hourly increments of dosage. Additionally, it can represent outcomes or improvements in a graph for easy follow-up or understanding. (B) Among patients initiated on CSAI at our center between 2013 and 2019, 42% of those who started and continued treatment for over 12 months were found to have done so. Interestingly, following the implementation of educational programs and technology integration for patient progress tracking, a notable increase in the proportion of patients was observed, with 76.9% of patients who started the CSAI treatment since 2020 continuing treatment over 12 months. Additionally, additive technology and educations have been conducted mainly since 2020, including web-based apomorphine registry, ChulaPD Plus application, electronic PD diary, daycare service, telemedicine, and experienced nurse training.