Stroke Prevention in Atrial Fibrillation (AF)

Detect. Protect. Perfect.Kent Surrey Sussex AHSN Spy Glass


Kent Surrey Sussex Academic Health Science Network (KSS AHSN) collaborated with Oberoi Consulting to implement the Oberoi Stroke Prevention in Atrial Fibrillation (SPAF) & Case Finding Service in 10 East Kent GP Practices (population 118,683 individuals) to facilitate the work of Clinical Pharmacists.


To improve the detection of AF and optimise use of anticoagulants through the implementation of a package of tools and resources, as AF-Related Strokes are severe and are associated with significant mortality and morbidity.


Implementation package: AliveCor Kardia Mobile Lead 1 ECG Devices, Virtual anticoagulation clinics, Oberoi SPAF & Case Finding Service, CVD Mentorship & Education Programmes, online platform with CVD shared learning & resources.

Data is Key

Oberoi SPAF & Case Finding service offers a systematic approach which is completely integrated within the GP clinical system so there is no need for add-on software.

It carries out a real-time analysis of patients who have AF and are at risk of stroke, based on certain search criteria which are already within the patient record.

To support perfecting anticoagulation it identifies whether incorrect doses of Direct Oral Anti-Coagulants (DOACs) are being given, enabling clinicians to correct doses to improve efficacy and reduce potential side effects.

For those on Warfarin it identifies which patients have time in therapeutic range (TTR) values in the system and those with a TTR < 65%.

Monthly dynamic reporting is delivered through the Oberoi SPAF & Case Finding e-portal to show the impact being made on Detect, Protect and Perfect vs baseline.

Reporting is available at practice, PCN and CCG level.

To read the full case study, as a PDF, please click this link

Impact So Far:

KSS Detect Protect


Perfecting treatment, monitoring patients and recording data is paramount to patient safety, whether anticoagulation takes place within or outside a practice.

Dosing can then be amended accordingly.

KSS Perfect

Patient Safety:

Perfecting treatment is key to reduce bleeding risk and ensure dosing is within the therapeutic range for both Warfarin and DOACs for stroke prevention.

Next Steps:

To scale the Detect-Protect-Perfect project model across the region, starting with all 67 East Kent Practices (click this link to see the full case study for potential impact).

Key Contact at KSS AHSN: Jen Bayly, Cardiovascular Programme Lead, KSS AHSN

To find out more about the Oberoi SPAF and Case Finding Service,
please visit:

Alternatively, call 01332 224 251 or email