The New Healthcare: AI-Driven Population Stratification, Proactive Medicine, and Predictive Analysis

Abstract Background The Covid-19 pandemic has highlighted structural and functional weakness of local health services. Italy carried out its reorganization with DM 77/2022, financed by Mission 6 PNRR of the CE. The model adopted aims to move from a reactive to proactive medicine, to be implemented close to the places where citizens live. The priority objective is to know data on the progress of chronic pathologies and non self-sufficiency using advanced digitalization tools. Methods 14 types of administrative data from 2022 to 2023, concerning 180000 (ISTAT data) people in the Lecce Social Health District (DSS Lecce), were analyzed with AI (Chat GPT). Results Thanks to algorithms, 6 categories of clinical complexity were identified. The analysis showed that the population assisted is 198696, for temporary presences, with the most represented age group being 50-55 years. Births decreased by 36% in 10 years (from 1681 to 1076), with 2197 deaths in 2023. 42,38% of the population (average age 38,58 years) did not use healthcare resources, while 57,62% (average age 54,19 years) required them. 48646 patients have cardiovascular disease, but only 10% with heart failure were actively monitored. 25047 have metabolic disease, 11195 are diabetics, 5929 have chronic respiratory diseases, 8167 chronic neurological diseases and 907 are cancer patients. Increasing age leads to polymorbidity and show signs of social, economic and health fragility. Conclusions the strategic objective of the Lecce DSS was management of chronicity according to specific care pathways, PDTA. Create healthcare teams capable of being case managers depending on the level of complexity (family doctors, nurses, etc). With the 2024 data there will be 3 consecutive years of analysis which will allow the development of predictive systems to identify population clusters at risk of increasing complexity and in need of proactive medical interventions, use of telemedicine with the support of a Territorial Operations Center. Key messages • AI-driven stratification supports personalized health plans to improve healthcare delivery, patient outcomes, and optimize resource allocation. • A new model of Population Health Management supported by Artificial Intelligence.