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Application of computer simulation modeling in the health care sector: a survey

Bozena Mielczarek and Justyna Uzialko-Mydlikowska
SIMULATION 2012 88: 197 originally published online 15 November 2010
DOI: 10.1177/0037549710387802

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 Simulation

Simulation: Transactions of the Society for

Modeling and Simulation International
88(2) 197216
Application of computer simulation The Author(s) 2010
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DOI: 10.1177/0037549710387802
a survey sim.sagepub.com

_
Bozena Mielczarek and Justyna Uzia11ko-Mydlikowska

Abstract
This article aims to present examples of computer simulation models that support decision-making processes in the
health care sector. The objective of this review is to propose a system of classification of health care topic areas
examined with the assistance of simulation methods. The categories described in literature were expanded and a detailed
taxonomy for sub-groups was formulated. Usefulness of simulation modeling techniques was investigated and an attempt
was made to correlate the simulation approach with a corresponding health care application group from the suggested
classification.

Keywords
computer simulation, decision, health care modeling, literature review, management

of alternative decisions, as well as to estimate any

1. Introduction
Managing a health care institution is as complex and
demanding as managing a large corporate organiza-
tion. The challenge faced by every public health care
unit is to balance two contending goals: to satisfy the
medical treatment demands of a constantly growing
population and to maintain costs at a dened level.
The fundamental objective is to improve eciency
while reducing costs.
Beginning in the 1950s, operational research and
related disciplines enabled health care managers to
investigate complex relationships among dierent
parts of a system and to make rational administrative,
economic, and medical decisions.1 The operational
research model oers a systematic approach to problem
solving and allows for the characterization of activities
of an existing system using mathematical modeling. The
analysis is carried out on a mathematical model, rather
than a physical one, or instead of experimenting on an
actual system. This approach facilitates formulation of
adequate decision problems, a process that is particu-
larly challenging in the health services systems where
the requirements of component elements overlap dier-
ent levels of management. It also makes it possible to
test dierent strategies and to assess possible outcomes
uncertainties that may inuence decisions and the
results. The key to eective planning is to understand
the way the system operates to the degree that will
enable one to predict its behavior suciently enough
in the future. The exibility of such a model permits
testing of hypotheses, decision rules, operative proce-
dures, and the structure of a system while assumptions
and constraints are changing.
One approach, based on mathematical models, that
successfully addresses problems in the health care
system is simulation modeling. A simulation is a
sampling experiment carried out on a computer.2 Law
and Kelton3 describe various types of simulation meth-
ods, such as discrete-event (DES), continuous, com-
bined discrete-continuous, and Monte Carlo (MC)
simulation. White and Ingalls4 have customized simu-
lations to given implementation strategies and have
Institute of Organization and Management, Wroc1aw University of
Technology, Poland.
Corresponding author:
Boz_ ena Mielczarek, Institute of Organization and Management, Wroc1aw
University of Technology, Wybrzeze _ Wyspianskiego 27, 50-370 Wroc1aw,
Poland
Email: bozena.mielczarek@pwr.wroc.pl

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198 Simulation: Transactions of the Society for Modeling and Simulation International 88(2)
classied them into continuous, Monte Carlo, discrete-
event, hybrid, and agent-based simulations. In this
study the main three will be addressed: DES, MC,
and continuous simulation represented by the system
dynamics (SD) approach. A specic type of DES is a
micro-simulation in which the individual outcomes of a
system realistic simulations of patient histories are
generated.
DES models3 are carried out on individual objects
(entities) as they move through a system, participate in
dierent processes, and consume material, nancial,
personal resources. The entities in a health care model
(usually but not necessarily the patients) may be
simultaneously involved in several activities and in
interdependent queues. Their progress through a
system depends on uncertainty associated with the
admission of objects into the system and the duration
of delay in internal processes. In the DES model, indi-
vidual patients are followed as they pass through a
system and dierent output measures needed to evalu-
ate system behavior are calculated. A second approach,
the SD,5 oers an alternative perspective on a system
under study, as it is specically designed to incorporate
the feedback mechanism. It does not focus on individ-
ual objects but rather on aggregate ows. Feedback
loops, non-linear relationships, and accumulation pro-
cesses help one to understand the structural reasons for
dynamic behavior and to reveal future trends, as well as
to uncover reasons for the observed changes. MC
modeling usually is of a static character.2 It is not suit-
able for an evolving system, but rather it estimates the
outcomes of a decision and the probability with which
these outcomes will occur. MC models are usually
developed in spreadsheets.
In recent years it has been reported that many
scientic studies focused more and more on the appli-
cation of the simulation approach in analyzing a wider
spectrum of health care management problems. The
prevalence of simulation modeling in the health care
domain does not parallel its application in the military
or logistic elds, but nevertheless its use in this area is
expanding. Initial studies primarily focused on hospital
management problems, but gradually models found
application in investigating emergency medical systems,
health care clinics, and public policy. The most recent
papers demonstrate the possibility of using simulation
to improve our understanding of epidemiological prob-
lems, which are important and pressing issues in current
times as the world is faced with the continued spread of
diseases such as Ebola, the Human Immunodeciency
Virus (HIV), Hantavirus, or even the emergence of new
inuenza strains.
A survey of the literature was conducted to deter-
mine the major up-to-date health care areas supported
by simulation models. This paper focuses on articles
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published between 1999 and 2006; however, we have
also included some of the more relevant earlier articles.
The aim of this paper is to describe the main trends in
the application of simulation modeling that are avail-
able to health care decision makers, bearing in mind
that the resulting bibliography should not be regarded
as the nal one. In this rapidly developing eld, new
articles are constantly appearing in scientic magazines
and new examples of applications wait to be included in
the list.
We have reviewed 168 papers published in peer-
reviewed journals and in the proceedings from recog-
nized international conferences (such as the Winter
Simulation Conference) from 1999 to 2006. We looked
for articles that described simulation models and their
topics, or their keywords, related to health care or
population health issues. Our objective was neither to
conduct a complete research of the eld nor to evaluate
the value of health care simulation modeling. Our
intention was to nd the most popular areas of interest
and to investigate the use of the three simulation
modeling techniques (DES, MC, SD). The results
regarding the application of simulation methods and
software packages used are discussed in the nal section
of this article.
2. Search strategy and selection
of papers
In our search we included the ACM Digital Library,
EBSCO databases (Medline, Business Source
Complete, Academic Search Complete), Elsevier and
Springer journals (Science Direct, Medline, Inspec),
SAGE Publications journals, and Winter Simulation
Conference proceedings for papers published between
1999 and 2006. The search strategy consisted of three
stages. In the initial stage, digital libraries were
scanned. A query was formulated to identify the
papers with word simulation in the title or in the
keywords and one of the words health, hospital, patient,
emergency department, outpatient, or surgery in the
abstract. During the second stage, the decision about
paper inclusion was made, based on the following
criteria: (1) the paper described a computer simulation
model; (2) the topic or the setting referred to the health
service delivery or to public health; and (3) a clear asso-
ciation with health care management issues existed. The
third criterion was added because we decided not to
include papers from two very broad application areas:
the medical decision making concerned solely with
clinical aspects and the area of education/training.
The last stage involved manual scanning of papers
from the Winter Simulation Conference 19992006.
The inclusion criteria remained the same as for journal
publications.
Mielczarek and Uzia1ko-Mydlikowska
Once the initial set of papers was collected, the
process of assigning followed. Decisions regarding the
area of application, the modeling method, and the soft-
ware package had to be made. This work was
performed independently by two authors and results
were compared. If a discrepancy arose, a discussion
proceeded and a consensus was usually achieved. In a
few disputable cases, in which consensus was not
reached, the paper was rejected. It should be empha-
sized, however, that the review shall not be interpreted
rigorously, as the presented models may be associated
with more than one application group. The unique
feature of the simulation approach rests in its general-
ity. Models are built to fulll more than one purpose
and thus may be simultaneously placed in several appli-
cation areas. We tried to dene the basic application
area of every examined model and we referred the refer-
enced article to this group. It is obvious, however, that
the model under consideration may be included in more
than one category, while the main problem range may
be a matter of argument.
The applied simulation method was in most cases
named by authors of the examined paper. However, if
it was not, then we deduced it from the models descrip-
tion. Only in sporadic cases the assignment could not
be made from among 168 reviewed papers we named
the modeling method in 156 cases.
The last assignment concerned the software package
used. This could be achieved only if the software pack-
age name was provided in the body of the article. If it
was not, then the model was assigned to the not-given
group. The detailed explanation regarding the rules
used for assigning groups is provided in Section 4.
3. Application areas
A broad taxonomy of articles describing DES models
that address problems encountered by health care
clinics up to 1997 was created by Jun et al.6 The authors
concentrated on applications of models to a single clinic
and to a multi-facility health care clinic. They distin-
guished between two main areas: (1) patient ow area,
including patient scheduling and admissions, patient
routing and ow schemes, scheduling and availability
of resources; and (2) allocation of resources with three
sub-areas, that is, bed sizing and planning, room sizing
and planning, sta sizing and planning. A systematic
review of the application of computer simulation
models in population health and health care delivery
between 1980 and 1999 was carried out by Fone
et al.7 The authors attempted to assess the extent and
quality of simulation modeling in the health care eld.
They enumerated ve topic areas: hospital scheduling
and organization, infection and communicable disease,
costs of illness and economic evaluation, screening, and
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199
miscellaneous. Mustafee et al.8 proled health care
simulation literature published between 1970 and 2007
to the various subject categories. One analysis aimed to
identify the health care subject areas modeled by the
four simulation techniques (DES, MC, SD, and agent-
based simulation). More specialized reviews are also
available. Cooper et al.9 reviewed the application of
modeling techniques in the treatment of coronary
heart disease. The authors found that DES models
were rarely used in the eld.
With the modication of several aspects of categori-
zation, we employed the classication as proposed by
Lagergren,1 who distinguished between four major
groups of operational research models applied in
health services: epidemiology, health and care systems
operation, health and care systems design, and medical
decision making. In our search for articles from the
medical decision-making eld, we looked for those
related to health care management, and consequently
articles that focused solely on the clinical side of deci-
sion processes (such as monitoring the progress of a
disease or assisting in the clinical interpretation of
data) were excluded from our survey. Next, we
extended the classication with the extreme events plan-
ning group. According to Altay and Green,10 there is a
clear distinction between routine emergencies and more
serious emergencies, such as disasters, catastrophes,
and terrorist threats. While both deal with the perfor-
mance of a system, the respective decision-making
processes dier drastically. Finally, to account for
the extensive representation of the rst two groups,
we propose to sub-group the taxonomy further.
Epidemiology, health promotion, health policy
(disease prevention) Simulation models are used to
forecast epidemiological events, the prevalence of infec-
tious diseases, and associated mortality (mainly HIV/
Acquired Immune Deciency Syndrome (AIDS)), car-
diovascular diseases, and other diseases, such as diabe-
tes and dementia. Simulation is also important in
decision making in the context of global health policy
and specically in national health prevention programs,
screening and vaccination campaigns, and planning of
intervention strategies.
Health and care systems operation This widely
represented set of applications relates to system perfor-
mance improvement issues. The presented models
determine how existing resources can be utilized more
eectively in areas of patient admissions, planning of
personnel work schedule, and planning of auxiliary
services. They also help to formulate an overall diagno-
sis of the performance of a system.
Health and care systems design This group of
models attempts to make future forecasts by estimating
anticipated population demands and subsequently allo-
cating resources as needed. A variety of solutions
200 Simulation: Transactions of the Society for Modeling and Simulation International 88(2)
geared toward distinct medical institutions (hospital,
ambulatory care center), or groups of them, are inves-
tigated. The planning process is conducted in terms of
quantity (optimization of the number of hospital beds)
and quality (ambulance deployment to assure a
balanced access to emergency system services).
Medical decision making Simulation models are
used to support the assessment of various operational
decisions in a medical practice, either in treatment and
monitoring of disease progress at the clinical level or as
support in treatment of individual patients.
Extreme events planning Simulation models are
adapted to determine the preparedness and eciency
of health care systems in cases of extreme events, such
as disasters (oods, earthquakes, epidemics) or bioter-
rorism attacks. Such models simulate responses to
reliably reproduced extreme events scenarios and may
help in improving the planning process.
3.1. Epidemiology, health promotion, and disease
prevention
3.1.1. Health policy evaluation and
planning. Decision makers responsible for global
health policy should have at their disposal essential
information that will enable them to determine the
implications of prevention activities and treatment
procedures in terms of morbidity, mortality, and
costs. Simulation models are of particular benet to
health policy makers who employ them as tools to
support their decisions when shaping the global
health policy, examining the short- and long-term
eects of particular programs, comparing their results,
and conducting the cost-eectiveness analysis.
The representative examples of the application of
simulation methodology in global health issues were
given by Lagergren.11,12 He constructed a simulation
model that provided supporting arguments for a
debate about the past and future of the Swedish
elder-care system. The main purpose of this analysis
was to estimate the future needs of publicly nanced
long-term care. Sutherland and Botz13 used the stochas-
tic simulation model to assess the eects of misclassi-
cation errors in the assignments to diagnosis related
groups (DRG). Eggleston and Yip14 applied the simu-
lation approach to carry out experiments that analyzed
the impact of Chinas payment reform on cost control
and on patient access.
The pediatric vaccination program serves as a good
example of the application of simulation in formulating
a global health policy program. The MC simulation
model developed by Jacobson et al.15 and Jacobson
and Sewell16 can be used to estimate the price distribu-
tion of four combination vaccines. The information it
yields allows health ocials to assess whether such
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combination vaccines should be stocked. It also
helps to determine the fraction of population
willing to purchase a given combination vaccine at a
specied price.
Diseases of the circulatory system are a leading cause
of death in European countries and many national
health care programs have made the combat against
cardiovascular disease their primary goal. Cooper
et al.17 presented a simulation model that describes
the treatment process of patients who have suered
from a coronary event. The model examines the conse-
quences of resource re-allocation and the eects of
dierent treatment policies on patient numbers and
treatments outcomes. Babad et al.18 proposed a DES
model to assess associations between the various
primary coronary heart disease prevention strategies
and health care resources. Prevention activities are
based on risk factors impacting policies and include
both the modiable physiological and behavioral risk
factors. Bronnum-Hansen19 explored the relationship
between the mortality caused by ischemic heart disease
and associated risk factors.
The usefulness of simulation models in understand-
ing the eects of national activities directed at reducing
tobacco use was described by Levy and Friend20 and
Levy et al.2124 The strategic goal of a national tobacco
campaign is to reduce negative population health
consequences and costs associated with smoking.
Some of these adverse eects become evident within a
relatively short time, as in the increased incidence of
low birth weight babies among mothers who smoked
throughout pregnancy; however, most symptoms are
delayed and develop over a long time before becoming
clinically apparent in older age. The health-related ben-
ets of anti-smoking policies will become evident in the
future and will depend on the age at which smokers
adopted the messages in these campaigns. A similar
study was conducted by Ahmad25,26 and by Ahmad
and Billimek,27 who constructed dynamic simulation
models to investigate the health and economic impact
of an increase in cigarette excise taxes. The authors
proved that raising taxes, as well as increasing the
legal smoking age to 21, would reduce cigarette
consumption and yield signicant economic benets
to the state. Mooy and Gunning-Schepers28 assessed
the health benets resulting from specic preventive
programs. These authors developed a simulation
model that investigates the three main areas with the
strongest impact on public health: cigarette smoking,
level of physical activity, and a healthy diet.
Simulation modeling was used by Jones et al.29 to
study diabetic population dynamics, focusing mainly
on prevalence and mortality, but it can also be
expanded to assess the morbidity and cost eectiveness
of intervention programs. Results of simulation
Mielczarek and Uzia1ko-Mydlikowska
experiments aid in identifying and selecting the most
eective public health strategies.
Models with a more general application have also
been developed. Brailsford et al.5 described the appli-
cation of SD to examine an entire health care system in
depth, in order to gain insight into the behavior of its
component elements. Dormuth et al.30 used simulation
to project the nancial impact of drug policy changes
on drug expenditures. Gandjour and Weyler31 investi-
gated the cost eectiveness of referring hip fracture
surgeries to high-volume hospitals (HVHs). Various
aspects of SD models applied to population health
issues were discussed by Homer and Hirsch.32
The number of patients awaiting organ transplanta-
tion has signicantly increased during the last decade.
Global policies for managing the donated organs are
the subject of an ongoing and heated debate because of
the delicate nature of this issue, as well as the diculty
in predicting the eects of a given policy. Simulation
serves as a valuable source of information prior to the
enactment of policy changes. It may also predict future
demands and resources needed in the management of
human organs and tissues.3339
3.1.2. Evaluation of intervention and treatment
programs. The simulation approach is used to evalu-
ate the quality of the prevention and treatment
programs in terms of cost, benets, and eectiveness.
Simulation experiments may reveal inecient programs
and may be helpful in establishing guidelines for health
policy planners.
Rauner40 cited numerous examples of simulation
models supporting decision processes in the area of
infectious diseases health policy. She distinguished
three main areas in which simulation models contribute
to shaping the AIDS policy: decisions about intervention
programs, decisions about resource allocation, and
general decisions. The third group concerns, for exam-
ple, an assessment of the demand for treatment, predic-
tion of consumption of hospital resources by
HIV-positive patients, or home health care resources
in AIDS treatment. Rauner presented the discrete
deterministic model to carry out a comparative analysis
of costs, advantages, and eectiveness of dierent inter-
vention programs and their inuence on the rate of
HIV/AIDS spread.
Cost eectiveness of diabetic foot prevention strate-
gies was evaluated by Rauner et al.41 The authors used
the Markov model in combination with the MC simu-
lation to assess and improve prevention strategies.
Baldwin et al.42 and Eldabi et al.43 developed a simu-
lation model to help health economists dene key fac-
tors of the Adjuvant Breast Cancer Randomized
Clinical Trial, in order to gain better understanding
of the problems associated with adjuvant treatment of
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201
breast cancers and to perform economic evaluation of
dierent treatment options.
Davies et al.44,45 used DES approach to investigate
dierent prevention and treatment policies in the areas
of screening and eradicating helicobacter pylori (Hp)
bacteria usually acquired in childhood, and in coronary
artery diseases. The rst model deals with a healthy
population, while the second is concerned with a
population aected by a serious and progressive
disease. Simulation has also been helpful in the assess-
ment of screening strategies for retinopathy46 and for
colorectal cancer.47
One of the key factors determining the success or
failure of prevention or treatment activities is peoples
behavior. Brailsford and Schmidt48 proposed a method
of incorporating such behavioral elements in the DES
model: specically they examined patients attendance
to screenings for diabetic retinopathy.
Static simulation models can be utilized to compare
screening programs for the early diagnosis of cancer,
including the criteria of eciency and cost eectiveness.
Cost eectiveness is determined by net cost per year of
life gained and the dierentiated design parameters may
concern the screening interval, the segment of the
population referred for screening, the expected partici-
pation rates, and age groups, as well as other factors.
Woodard et al.49 conducted a simulation study to assess
the value of sampling design for the Injection Safety
Survey. One example of a cost-eectiveness study in
the treatment of osteoporosis was given by Stevenson
et al.50,51
A DES study to examine the demand for treatment
in a population of end-stage renal disease patients was
presented by Davies and Roderick52 and Davies.53
3.1.3. Spread of infectious diseases. Epidemiologic
simulation models are designed to predict the rate of
spread of epidemics, as well as to assess their economic
consequences and to estimate the future nancial
resources needs in the treatment and cure of a growing
number of infected population groups.
A SD model to predict the spread of malaria in
African country was developed by Flessa.54 The
authors intention was to improve knowledge about
the eects of malaria-control programs. A similar
research goal was formulated by ORegan and
Moles,55 who aimed to expand knowledge about the
spread of the Ebola virus. These authors chose the
SD approach. Grais et al.56 examined the inuence of
air travel on the spread of annual inuenza in the USA
and found a strong correlation between the volume of
air travel and incidence of inuenza. The spread of HIV
among injection drug users was studied by Raboud
et al.57 The authors applied the MC simulation to
explore the relationship between a needle-exchange
202 Simulation: Transactions of the Society for Modeling and Simulation International 88(2)
program and a decrease in the spread of HIV. A SD
simulation model was developed by Evenden et al.58 in
order to observe patterns in the spread of Chlamydia.
The model demonstrated the dynamics of infection and
the cost eectiveness of screening.
Zaric59 presented a model that simulated the rate of
spread of infectious diseases through inter-personal
contact within a social network. The model estimates
the dierences in disease prevalence and the total
number of new infections, taking into account dierent
modes of inter-personal contact. Vieira et al.60 and
Rauner et al.61 designed simulation models to aid plan-
ners and clinicians in evaluating dierent strategies of
prevention of the mother-to-child transmission of HIV.
A stochastic epidemiology model, presented by
Mather,62 was applied to assess the spread of blood-
borne virus Hepatitis C. This model focused on analyz-
ing risks among individuals.
The spread of tuberculosis (TB) and HIV disease
was modeled by Hughes et al.,63 who use the DES
model. This model was designed to evaluate the eects
of new strategies aimed at reducing TB transmission in
countries with a high prevalence of HIV. An interesting
MC cost-simulation model was described by Liu et al.64
The model calculated the long-term economic implica-
tions of employing HIV-infected workers. Barth-Jones
et al.65 developed a discrete model to simulate the
dynamics of infectious disease transmission. Adams
et al.66 presented a tool kit that simulates realistic trans-
mission of infectious diseases.
Bennett et al.67 described a study in which the risk of
secondary transmission of variant Creutzfeldt-Jakob
disease (vCJD) through surgical instruments was
assessed. While this mode of infection was not reported,
a related disease, sporadic CJD, has been transmitted
via brain and eye surgery. The authors created a SD
model to follow routes of infection.
3.2. Health and care systems operation
This eld of application generated such interest among
simulation modelers, that further proling was recom-
mended. We have identied ve sub-groups, but it
should be noted that it is not characterized by a clear-
cut distinction between each one. For example, two
sub-groups, Determining the optimal capacity of the hos-
pital resources and Resource allocation, cannot always
be precisely separated. Nevertheless, keeping in mind
the objective of our study, it seems that a closer look
at the potential application areas will also be of benet,
even at a lower level of detail, which is justiable
because of a particularly large number of models.
Models from this cluster support administrative deci-
sions and provide methods to study system
performance and to test dierent alternatives of a
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systems operation. They concern such issues as
improvements in patient appointment systems, waiting
list management, sta scheduling, planning of auxiliary
services, resource re-allocation, and overall problems,
such as the diagnosis of system performance and anal-
ysis of the consequences of any proposed changes.
3.2.1. Estimating and evaluating the potential effect
of the organizational changes. Simulation experi-
ments are carried out to examine the eectiveness of a
given health care system after the changes to be tested
have been introduced. The primary objective is to eval-
uate dierent alternatives of system operation in order
to optimize its performance measures.
The tested scenarios may concern small but signi-
cant proposals related to improvements in the service
delivery, such as the addition of a registration clerk
during peak hours, extension of the operating hours,
introduction of a fast track care center,68,69 allocation
of a number of rooms specically for patient prepara-
tion,70 evaluation of an addition of beds to the intensive
care unit (ICU),71 or implementation of some qualita-
tive improvements, such as the addition of a ticket
dispenser, later to be considered by a triage nurse, or
hiring additional nurse sta to assist patients in lling
out information sheets.72 The issues considered may
also be of a more fundamental nature, for example
looking at alternatives in patient arrival schedules, ana-
lyzing the eects of integrating a cancer treatment
center with radiation oncology,73 introducing improve-
ments at an ambulatory vaccination point in clinics
serving the indigent and the working poor,74 evaluating
possible alternatives to the organization of patient ow
at a large medical center,75 synchronizing stang deci-
sions with patient ow,76 comparing two patient triage
systems in an emergency department,77 introducing a
new triage-team system in an emergency department,78
nding the number and the types of residents that will
maximize throughput and minimize total time spent in
a given system,79 improving operating room (OR)
eciency,80 extending the operating hours of operating
theatres,81 increasing the number of sta, using a
six-day weekly schedule,82 and predicting the perfor-
mance of an emergency department after hospital facil-
ities have been expanded.83 The simulation approach is
also applied to test the outcome of improvement
options directed at cost reduction, waste elimination,
and patient satisfaction.8487
Ramakrishnan et al.88 assessed radiology services to
classify the changes made to an existing workow at a
computerized tomography (CT) scan area resulting
from the introduction of digitized archiving system.
Taylor and Dangereld89 employed SD to explore the
eects of changes on the patient referral chain, when
implementing a shift in cardiac catheterization services
Mielczarek and Uzia1ko-Mydlikowska
from tertiary to secondary level for low-risk investiga-
tions. Ferrin et al.90 investigated the value of an incen-
tive program in the OR environment. The DES model
used in determining the cost eectiveness of a set of
proposed changes in surgical and anesthesia care was
discussed by Stahl et al.91
Some models focus not on the patients but on other
entities moving through a health care system. Wong
et al.92 presented two simulation models built to
assess the advantages of implementing an electronic
medication ordering, dispensing, and administration
system instead of running a manual one.
3.2.2. Diagnosis of the system. Simulation models
are used to gain information about activities within a
health care system (waiting times, utilization rates,
queue times and lengths, costs) and to indicate the
reasons for mistakes in patient care and during
the treatment processes. They may help to forecast
the consequences of decisions made, to detect unfavor-
able trends, and to make improvements to the general
performance of a system. Models from this application
area are usually directed at hospital administrators and
perform the role of an information system. Moreno
et al.93,94 Martin et al.95 described models that allowed
hospital administrators to obtain information about
the state of the hospital through reports and
graphs and to experiment with dierent control
measures to uncover the most suitable one. The simu-
lation model was supported by a knowledge-based
system, which used simulation as a step in the
reasoning process.
More specialized applications have also been devel-
oped. Kim et al.96,97 presented a model of a hospital
ICU to study the process of admission and discharge.
The model was designed to help hospital managers to
nd alternative policies for improving system perfor-
mance and to reconcile the units capacity with the
current demand. The issue of ICU performance was
also addressed by Masterson et al.,98 who used a DES
model to identify desirable adjustments. Kuno et al.99
developed a simulation-based approach as a support
tool for decision making in planning a mental health
system. The authors studied the impact of changes
made to input parameters on the overall system perfor-
mance, trying to nd the alternative ways to reduce
congestion. A geriatric departments performance was
simulated by El-Darzi et al.100 in order to evaluate the
patient ow and to measure bed occupancy.
Hospital emergency departments101104 are the
frequent subjects of diagnosis-type studies. The simula-
tion model examines patient ow and an in-depth anal-
ysis is carried out with regard to the waiting times and
time spent by a patient at each stage of the treatment
process.
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203
System diagnosis may concern not only the institu-
tion as a whole, but also the particular processes as
well. Abellan et al.105 described a model that analyzed
a renal transplantation list and predicted its behavior.
The model integrated information about the process of
registration of donors with the process of organ distri-
bution. Kopach et al.106 and Rytila and Spens107
discussed models that can forecast shortages of blood
products in a hospital. Glick et al.108 introduced simu-
lation as a means to measure activity costs for a specic
health care procedure. They used simulation to trace
the direct costs of radiological imaging in an emergency
department. Zayas-Caban109 proposed using a discrete
simulation model to study access to health care in a
community.
3.2.3. Staff scheduling. Sta scheduling-related
issues appear in the earliest studies of health care
systems.110 The goal of these models is to reduce patient
throughput times by determining the appropriate sta-
ing levels. The system under study usually is an emer-
gency department, although models of other units, such
as hospital ORs, have also been developed. The model
mirrors patient ows through a system by taking into
account the age of a patient, patient care category, the
diagnosis, urgency of care, probability of complica-
tions, and other factors. The detailed data concerning
patient arrival patterns and sta (doctors, nurses, tech-
nicians, auxiliary personnel) activities and schedules are
the required input. The way the patient enters a system,
the diagnosis made, and patients acuity determine the
probability distributions describing the type of patient
ow through the system, the activities performed, and
resources consumed. An analysis of performance
measures (i.e. length of stay, waiting times in queues,
and personnel utilization rates) allows for the evalua-
tion of various personnel schedules. While the objective
of these studies is to decide on the appropriate stang
level, the key restriction before the implementation of
changes can take eect is to maintain the quality of
health care services and, in particular, prevent the
situations associated with increased risk of mistakes
in medical decision making. Such analyses can be
used to improve the process of delivery of health care
services without the necessity of employing additional
medical personnel.
Spry and Lawley111 addressed the problem of sta
scheduling in hospital inpatient pharmacies and
proposed a simulation model to estimate the inuence
of stang and work schedule operational policy on the
time it takes to process medication orders.
Sta scheduling sometimes is only one component
of large-scale projects. Baesler et al.112 preceded
estimation of stang levels by rst simulating the
maximum level of demand that an emergency room
204 Simulation: Transactions of the Society for Modeling and Simulation International 88(2)
(ER) was able to serve. Centeno et al.113 investigated
the changes in sta scheduling concurrently with
adjustments in scheduling the patients. Some authors
combine simulation with other operational research
techniques to nd the optimal sta schedule. Centeno
et al.114 used discrete simulation to establish stang
requirements for each period and an integer linear pro-
gram to nd the optimal number of sta members to
start at each shift.
3.2.4. Determining the optimal capacity of the
hospital resources. Hospital services constitute one
of the biggest and most complicated industries in the
world. Mathematically, hospital care can be dened in
terms of a multiple stochastic system operating in a
milieu of rapidly changing random variables, complex
constraints compounded by a constant struggle with
insucient resources. The unique attributes of the
simulation approach allow for consideration of each
of these specic complexities (e.g. rules of the patient
admission process), uncertainty (e.g. uctuations
in daily and annual number of patients), variability
(e.g. patients length of stay depending on the type of
ward), and limitations in the number of available
resources. By following patient ows through the hos-
pital, discrete simulation models record the utilization
of particular resources over time (hospital beds, oper-
ating theatres, medical sta, etc.) and aim to balance
them. The objective is to assist managers with the plan-
ning and management of hospital beds/specialist equip-
ment,115118 operating theatres and workforce needs,119
using catheterization capacity,120 or solving periodic
problems with lack of hospital beds.121 The model
may seek optimal scheduling of nurses in the ICU,122
the maximal capacity in a surgical suite,123 or the
number of ICU beds needed.124 Ridge et al.124 observed
a non-linear relation between the number of beds, the
average level of bed utilization, and the number of
patients transferred into another ward due to the lack
of bed space.
A set of recommendations on how to construct a
computer simulation model of an emergency depart-
ment was presented by Huddy et al.125
3.2.5. Resource allocation. Undue waiting times for
health services may not only stem from an insucient
amount of available resources, but also from their
improper allocation within the system. Simulation
may be used to examine the geographical distribution
of service providers126,127 or to achieve a more ecient
allocation of hospital beds among dierent hospital
wards and the ICU.128
Location and relocation models of emergency med-
ical systems are popular among researchers.129131
These models suggest such deployment of xed and
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mobile resources that would allow one to achieve
some of the predetermined objectives such as, for exam-
ple, the acceptable value of hospital transfer time or
patient waiting time, while at the same time being
cost eective. The proposed solution may identify an
optimal location for emergency service facilities, ambu-
lances deployed within a specied area, personnel and/
or equipment assigned to existing facilities, or an
improved organization of working shifts.
The complex issue of allocating various xed
resources in a health care center was presented
by De Angelis et al.132 The authors tried to nd an
optimal conguration of dierent types of servers and
facilities (medical personnel, beds, medical instruments)
that would keep the total time spent in a system at a
particular level and would not exceed the allotted
budget.
A noteworthy variant was presented by Pasin
et al.133 The authors used simulation methodology to
study the impact of resource (equipment) pooling in a
group of local community service centers. Interestingly,
they found that unlimited pooling generated the largest
reduction of costs.
3.2.6. Appointment systems. The appointment
system is usually applied when admitting patients to
hospital wards or registering persons in outpatient
clinics. The overall problem is to control patients wait-
ing times by applying an appropriate, sensitive, and
responsive appointment procedure in which the esti-
mated patient ow corresponds to the available
resources. Some authors try to minimize the delays
after patients arrive in the clinic, while others concen-
trate on the time that patients have to wait to get an
appointment. Generally, studies concentrate on the
unacceptable length of waiting time for service. The
results show that patient waiting times can be signi-
cantly reduced through improved planning of the
scheduling system.
A simulation model may be used to support deci-
sions in the management and scheduling of elective
surgery cases in a public hospital, as well as for
non-elective admissions. Everett134 presented three
main areas of applications of the model: (1) as a real-
time decision-support system to control the ow of elec-
tive surgery patients to an appropriate hospital; (2) as a
monitoring tool to analyze past eectiveness of sched-
uling protocols; (3) for planning purposes to investigate
alternative congurations and redeployment of
resources. Moore135 proposed a way to include
unplanned admissions when predicting the average
number of occupied beds. An interesting paper was
presented by Giachetti et al.136 The authors used DES
to investigate the inuence of a new scheduling
approach called Open Access on patient throughput
Mielczarek and Uzia1ko-Mydlikowska
time. To understand the relationships between the
scheduling system, patient demand, and service capac-
ity they developed a SD simulation model.
The simulation model makes it possible to correlate
random patient arrivals and service time distributions
with dierent types of patients attending the clinics.
The tested scheduling policies may be described in
various ways:137 patients are scheduled to arrive at an
appointed time, scheduled patients take numerical
priority over walk-ins on the arrival chart, scheduled
patients are assigned with even numbers and walk-ins
with odd numbers, the recommended appointment time
intervals are varied. When dealing only with the sched-
uled patients,138 dierent algorithms may be applied to
test alternative policies, including random scattering,
leaving buer periods in which no patients are sched-
uled, keeping regular time intervals between arriving
patients, or using elective-surgery quotas139 with a
scheduling window to enhance the operation of
the ICU.
The appointment procedure in elective surgical care
diers from scheduling in outpatient departments.
Rohleder and Klassen140 presented a simulation
model with a rolling horizon appointment system and
variable demand load in outpatient clinics. The authors
tested several management policies using dierent over-
load rules and varying the timing of these rules (such as
double-booking clients and server overtime) with the
dierent demand patterns and various performance
levels. Patient classication, according to Cayirli
et al.,141 inuences the eectiveness of the appointment
system in outpatient services and equipment-related
medical services. The authors investigated the eects
of a classication scheme and developed practical
guidelines for managers. Vasilakis and Kuramoto142
compared two methods of scheduling outpatient clinic
appointments. They considered the variable availability
of surgeons due to other commitments and activities
within their clinical practice. Guo et al.143 and
Wijewickrama and Takakuwa144,145 examined dierent
appointment schedules when trying to minimize the
delays for patients and maximize the overall eciency
of the clinic. They dened three environmental factors,
namely no-shows, dierences in the time of consulta-
tion, and variation in times of walk-ins, which most
impact the eectiveness of an appointment system.
An interesting paper on surgical case scheduling and
sequencing in the post anesthesia care unit (PACU)
was presented by Marcon and Dexter.146 The authors
studied the inuence of rules of timing surgeries on the
hourly number of patients staying in the PACU and
resulting nurse stang demands, using DES. The
simulation model created by Baker and Atherill147
examined the dierent strategies of appointment sched-
uling for breast cancer screening.
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205
While constructing the models of patient admissions
to the health care unit, the importance of accuracy of
input data analysis must be emphasized. Issues relevant
in this area, such as the dierent sources of data neces-
sary to carry out the analysis, the possible methods that
could be applied, and examples of the obtained results,
were discussed by White.148
3.3. Health and care systems design
The simulation approach is particularly advantageous
in measuring the potential impact of planned long-term
strategic decisions resulting in big organizational shifts
aecting the population of a given region. A model
helps to elucidate the relationship between the planned
schemes and access to health services, taking into
account the availability of various hospital resources,
bed capacity, and the volume of care. Location-alloca-
tion models have been used extensively to study the
consequences of the dierent but geographically related
decisions.
Simulation is useful when planning a new health
center149151 or expanding an existing one.152154 It
can be used to predict the future capacity requirements,
facility design, and stang levels that would lead to
best utilization of the resources possessed and the high-
est client satisfaction.
Redesigning of phlebotomy and specimen collection
centers was supported by a simulation model developed
by Rohleder et al.155 The authors used the discrete
simulation to design a more eective set of facilities
and made recommendations for short- and long-term
resource changes. Another model was developed with a
SD approach to predict new patterns in demand and
examine the possible adverse eects on a new system.
Pulat et al.,156 rather than studying the ways of
improving current practices in hospitals, conducted a
study to determine the health care needs in a region and
generated the best scenario for primary care delivery.
3.4. Medical decision making
The simulation approach can be used not only to study
the process-structural management solutions, but also
to assess the cost eectiveness of dierent medical inter-
ventions or to evaluate the treatment policy at the clin-
ical level, as well as for an individual patient.
Anderson et al.157 developed a simulation model
using MC and SD method to estimate the expected
eciency of Coronary Artery Bypass Graft (CABG)
operations. An expanded model can be used to extrap-
olate information necessary for planning, for example
the required resources and costs, from a limited amount
of patient and hospital data. Feyrer et al.158 performed
a simulation on a sub process of patients clinical
206 Simulation: Transactions of the Society for Modeling and Simulation International 88(2)
experience during an inpatient stay for an elective
CABG in order to study the potential for speeding up
the daily patient throughput in the OR. Shechter
et al.159 provided further evidence of the usefulness of
simulation modeling in the evaluation of treatment
policies. They used the MC micro-simulation model
to test a wide set of assumptions and treatment policies
related to the HIV-positive patient population, focusing
on two specic components of HIV progression: adher-
ence and acquisition of resistance. The results obtained
from the simulation model serve as the basis for a
reasonable comparison between treatment policies,
such as when to begin or when to switch therapies.
Another example of the potential for application of
simulation models in medical decision making is in
the area of cancer treatment, and specically in chemo-
therapy. Van Merode et al.160 proposed a dynamic
simulation model to calculate the expected patient wait-
ing times and costs for the various combinations of
patient and cytostatic drug types as part of
chemotherapy.
3.5. Extreme events planning
Before 11 September 2001, the development of plans of
rescue activities in extreme situations concentrated
primarily on natural disasters, such as weather threats
(ood, re, tornado, etc.), trac problems (railway
catastrophes, trac catastrophes with multiple victims)
or industrial incidents (re, explosion, contamination).
After 11 September, the local emergency agencies in the
USA were made responsible for working out plans in
case of a terrorist attack. This resulted in a spur of
scientic investigation in this area, also using means
of simulation methods.
Brady161 presented assumptions for a simulation
model to analyze and estimate the risk, to determine
the capability for reacting to emerging threats, and to
unearth any weak points hidden within the system.
Taae et al.162,163 considered the issue of hospital evac-
uation in cases of weather threats, hazardous material
spills, or terrorist incidents. The adequacy of applying
simulation models to study the process of evacuating
large groups of people was also analyzed by Court
et al.164 The issue of optimal management of hospital
resources in a setting of a disaster was studied by
Schenk et al.165 Scenarios with dierent combinations
of resources in an emergency department were
simulated with a DES model. The costs of patient
examination during everyday system work and during
the extraordinary circumstances in the event of a
disaster were found. Fawcett and Oliveira166 built
a simulation model to study the response of the
regional health care system in the event of an
earthquake.
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Miller et al.,167 Patvivatsiri,168 Lee et al.,169 and
Hupert et al.170 ran an experimental scenario simulat-
ing a bioterrorist attack to estimate the appropriate
resources and sta level in the ER department168 and
planning the response167 in a rural acute-care delivery
system. Miller et al.167 developed two models: one
representing the spread of disease as a consequence of
an attack and a second one to follow the care given to
the victims. Lee et al.169 described a decision-support
system based on the simulation environment in plan-
ning large-scale emergency-care clinics. A similar issue
was studied by Aaby et al.171 who built a simulation
model designed for clinic planning to minimize the
threat of an outbreak of contagious disease and by
Hupert et al.,170 who determined required stang
levels in dierent bioterrorism response scenarios.
Gunes and Szechtman172 proposed a simulation
model to allocate helicopter ambulance services for
individual operator/small operators. This study consid-
ered the system response in urgent situations and the
issue of patient transport from one hospital to another.
A simulation model of a casualty evacuation system
under war conditions was presented by Nuhut and
Sabuncuoglu.173 The authors ran a DES model to
analyze the performance of an existing system and
then to improve patient ow processes by proposing
new logistic policies.
4. Discussion
4.1. Simulation modeling methods
Simulation is a set of modeling techniques used for
representing a system in the simulation model and con-
ducting experiments on this model using a computer.
The aim of simulation is to mimic the behavior of a real
object and to expand the knowledge about a system
through observations conducted on the model.
Simulation does not arrive at distinct solutions to prob-
lems, rather it helps in the understanding of a problem
and reinforces the debate between the problem owners.
Simulation methods are categorized in various ways,
but the most common classication distinguishes the
stochastic and deterministic types. Stochastic simula-
tion is represented mainly by the DES and the MC
method, while deterministic simulation is usually iden-
tied with SD. Micro-simulation models, which
recently gained popularity in the treatment of epidemi-
ology and public health issues, may be classied into
DESs without compromising universality.
To determine which problem areas are preferred by
the three simulation approaches (DES, MC, and SD)
mentioned above, a review of 168 articles published
between the years 1999 and 2006 was conducted.
Mielczarek and Uzia1ko-Mydlikowska 207

We were able to classify the majority of the presented
models (156) into one of the categories mentioned in
Section 3, taking into account the three modeling tech-
niques. We excluded review-type and methodological
papers, as well as those in which the precise simulation
approach was not readily apparent.
DES is denitely the preferred modeling technique
(Table 1) and, together with the MC stochastic simula-
tion method, is the most popular tool applied in anal-
ysis of health care problems. The predominant use of
the stochastic simulation model is clearly evident
throughout all of the reviewed publication years.
We found that the DES is a popular tool for analyz-
ing operations within health care systems (Group 2,
Table 2) and epidemiology and health policy (Group
1, Table 2). The growing trend can, however, be attrib-
uted to SD applications as well. This approach is
selected mainly to tackle issues in epidemiology and
disease prevention (Group 1, Table 2) and the
number of applications of SD in this area is evidently
not decreasing. A growing interest among simulation
modelers in this tool was observed starting in 2005.
Dierences in application areas between the DES
(considered jointly with the MC method) and SD are
clear. Epidemiologic and disease prevention models are
concerned with very large populations and the stochas-
tic simulation is challenged with a sizable collection and
processing of vast amounts of data. SD, not being a
stochastic technique, not only does not require infor-
mation about an enormous number of entities but also
allows for better insight into the general relationships
between parts of a system and analysis of feedback
mechanisms. Therefore we can predict that this area
of SD applications will grow in the coming years.
Our results signicantly dier from the statistics
obtained by Mustafee et al.,8 who found that MC is
the method most often applied (142 papers out of 201
included in their study), while DES was recognized in
only 40 of the papers. These discrepancies may be due
to several reasons. The most signicant is probably the
dierence between the databases that were researched
in both reviews. The comparison of journal names
shows that the two reviews do not overlap. Mustafee
et al.8 scanned a bibliographic database with a high
journal impact factor, while our review includes articles
from other sources as well (i.e. other recognized jour-
nals and the Winter Simulation Conference proceed-
ings). The journals with the highest number of MC
papers registered by Mustafee et al.8 do not appear in
our study (i.e. Environmental studies (28) or Public,
environmental & occupational health (24)), while some
that are considered in our survey (such as Health Care
Management Science (30)) are not included by
Mustafee et al.8 In addition, we have considered
papers from the Winter Simulation Conference (over
50 positions), from which many of the DES applica-
tions were cited. Another factor dierentiating the
two reviews is associated with the inclusion criteria.
Mustafee et al.8 diagnosed MC applications in clusters,
such as assessing health risks from exposure to certain
elements (60 papers) or methodology papers (16),
which were not included in our study. The third

Table 1. Simulation methods used in the published models

1999 and 2006 and

Simulation method Number Percentage before 2000 2001 2002 2003 2004 2005 after

Discrete-event 118 75.64% 15 9 9 18 19 12 17 19

System dynamics 23 14.74% 1 1 3 3 1 2 6 6
Monte Carlo 15 9.62% 0 1 1 2 2 5 2 2
Total 156 100% 16 11 13 23 22 19 25 27

Table 2. Distribution of simulation methods among five distinguished application groups

Simulation method Total Group 1 Group 2 Group 3 Group 4 Group 5

Discrete-event 118 23 76 8 1 10
System dynamics 23 19 2 0 2 0
Monte Carlo 15 12 2 0 1 0
Total 156 54 80 8 4 10
Percentage 100% 34.62% 51.28% 5.13% 2.56% 6.41%
Group 1: epidemiology, health promotion, health policy; Group 2: health and care systems operations; Group 3: Health and care systems design;
Group 4: medical decision making; Group 5: extreme events planning

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208 Simulation: Transactions of the Society for Modeling and Simulation International 88(2)

Table 3. Distribution of discrete-event simulation method among six sub-groups of Health and care systems operations group
(Group 2)

Group 2 Group 2.1 Group 2.2 Group 2.3 Group 2.4 Group 2.5 Group 2.6

76 25 16 5 10 7 13
Group 2.1: effect of organizational changes; Group 2.2: system diagnosis; Group 2.3: staff scheduling; Group 2.4: optimal capacity of the resources;
Group 2.5: resource allocation; Group 2.6: appointment systems.

Table 4. Distribution of simulation methods among the sub-groups of Epidemiology, health promotion, health policy group (Group 1)

Simulation method Group 1 Group 1.1 Group 1.2 Group 1.3

Discrete-event 23 8 9 6
System dynamics 19 14 0 5
Monte Carlo 12 6 3 3
Group 1.1: health policy evaluation; Group 1.2: evaluation of intervention and treatment programs; Group 1.3: expansion of infectious diseases.

reason for the observed dierence may lie in the assess-
ment methodology. Finally, when reviewing the papers
we tried to indicate the main modeling method and MC
usually came up as the supporting technique used to
analyze the sub-problem or to conduct an initial study.
The most strongly represented application area is
Health and care systems operation (Group 2) modeled
by the discrete-event approach. Almost half of the clas-
sied papers (76 out of 156) concern problems from this
application area supported by the DES method.
We found (Table 3) that issues most frequently under-
taken by modelers in this sphere focus on examination
of the eectiveness of health care system, as a conse-
quence of incorporated changes (Group 2.1) and on
system diagnosis (Group 2.2), although the other
sub-groups have also numerous representations (parti-
cularly group 2.6, i.e. patient scheduling).
Epidemiology issues (Group 1) are widely addressed
by both deterministic and stochastic simulation models
(Table 4). DES is frequently used for simulating disease
progress in order to evaluate treatments, dierent
options of prevention, and other interventions.
It deals with variability and uncertainty, thus it is a
suitable tool for understanding realistic stochastic
problems. SD models capture the dynamics of the
disease and provide key insight into better understand-
ing of the spread of infection. The model does not
follow the course of an individual patient but sheds
light onto the general structure of the problem and
the relationships between its component parts.
Similarly to Jun et al.,6 we have also found that sim-
ulation is being applied with the combined support of
other quantitative analysis methods, such as integer
programming, regression models, and Markov
models. The simulation is not an optimization tech-
nique. It is, however, the natural objective of many
simulation studies to nd the best solution from
among the dened constraints. For this reason, the
operational researchers try to enhance the simulation
modeling capabilities with optimization techniques,
sometimes delivered as add-ins with simulation pack-
ages (OptQuest with Arena, ProModelss SimRunner
Optimization) and sometimes as separate tools.
4.2. Simulation software
Simulation models are created using various and
constantly evolving computer tools. Stochastic and
deterministic simulations were historically processed
on separate programming packages (such as GPSS
for DES and Vensim for SD). However, a trend can
be observed in the majority of software towards mixed
approaches combined into one complex platform,
for example Simul8 for DES and Simul8-tanks objects
for SD.
Based on the descriptions given in the reviewed
papers, we have distinguished 12 main software tool
groups (Table 5). Most of the group names are self-
explanatory, for example Arena, Stella, Vensim, and
Excel. These groups take their name from the software
tools they represent. The programming language group
includes models coded with general-purpose program-
ming language, such as Delphi, C and Visual Basic.
Models that combine dierent tools (e.g. Arena with
Visual Basic Application and Microsoft Access,
Arena and ProcessModel, ProModel, and
Manufacturing Simulation) form a compound group.
If a particular tools name could not be found in the
paper, the model was placed in the not-given group.
Sometimes authors named the model but did not
link it with the specic software. In such cases the
papers were also placed in the not-given group.

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Mielczarek and Uzia1ko-Mydlikowska
Table 5. Simulation software used in the published models
Stochastic approach Deterministic
(DES MC) approach (SD)
(1) Arena 28 (2) Not-given
(2) Not-given 27 (3) Programming language
(3) Programming language 25 (11) iThink/Stella
(4) MedModel 9 (12) Vensim
(5) Simul8 5 and assist with future resource requirements in the
(6) Microsoft Excel 5 (10) Other tools
(7) MicroSaint 4
(8) Compound 4
(9) Extend 3 It was identied that most research concentrated on
(10) Other tools 23
Group other tools is composed of software packages
mentioned less than three times in a reviewed sample
(e.g. ABCSim, XCELL, AweSIM!).
Stochastic models are mostly created using the
Arena package but the usage of programming
languages is also prevalent. The SD approach prefers
general-purpose programming languages and places
Stella software in the second position (beside the
not-given group).
An interesting observation concerns software pack-
ages that are specically aimed at the health care indus-
try, such as MedModel. It is observable that the
majority of applications are created using general-
purpose software instead of industry-specic tools and
the explanation for this may lie in the fact that
academics are active in many operational research
elds not limited to health care issues. They conduct
dierent simulation projects (manufacturing indus-
try, supply chains, social issues) and are familiar with
the general-purpose software and appreciate its
exibility.
5. Conclusions
We have presented a survey of 168 papers published in
peer-reviewed journals and in proceedings from recog-
nized international conferences from 1999 to 2006. Our
objective was to identify the leading areas of health care
related problems modeled by the three main simulation
approaches (DES, MC, and SD) and to uncover trends
in the simulation software usage. This study proves that
simulation addresses a wide range of health care man-
agement problems. Our survey, which describes the
diversity of potential areas of application, reveals the
extent of issues to which running a simulation can con-
tribute. Models are created: (1) to support global health
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209
policy, to evaluate treatment and intervention
programs, to forecast the epidemiological trends of
chronic diseases, infectious diseases, cancer, and heart
diseases; (2) to improve performance of health care
7 systems using comprehensive diagnosis, to assess the
6 impact of potential organizational changes, to analyze
5 administrative issues such as sta scheduling, appoint-
4 ment schemes, and resource allocation; (3) to estimate
1
context of business planning; (4) to support operational
decisions in medical practice; and (5) to assess health
care systems preparedness and eciency in cases of
extreme events.
analyzing the performance of health care systems.
Approximately half of the literature included in the
studied sample (80 out of 156) focused on current
resource allocation, organization of appointment
systems, sta scheduling, and other issues related to
administrative and operational decisions. The next
leading area of application concerned health policy for-
mulation (54 out of 156). Using simulation, an experi-
mental environment can be created in which the eects
of short- and long-term policy changes and intervention
strategies can be evaluated. Simulation is also well
suited for investigating the spread of infectious diseases,
which can reveal the dynamics of an existing or a poten-
tial epidemic.
Some conclusions about the methodologies and soft-
ware trends were also drawn. Our analysis has shown
that the discrete-event approach is the commonly
preferred method and has been extensively used in the
majority of distinguished applications (118 out of 156).
The advantage of DES stems from its exibility, as well
as the ability to handle variability, uncertainty, and
complexity. It allows for an assessment of eciency
of a given system, performance of the what-if analysis,
as well as the possibility to design a new system. On the
other hand, SD may provide for the better understand-
ing of performance of a large and complex system
allowing for both qualitative and quantitative problem
analysis. The areas that specically attract SD modelers
include global health policy and epidemiological issues.
MC, the third observed technique, is commonly
employed as a support tool in the various simulation
projects and it is of primary use in evaluating the
economic eectiveness of a prevention or treatment
program, calculating its long-term economic cost impli-
cations as well as testing a wide set of assumptions and
treatment policies involving random factors.
The application of a variety of simulation software
to address problems in health care supports the obser-
vation that there exists a wide spectrum of choices
available to authors. Advanced simulation packages,
general programming languages, and spreadsheets
210 Simulation: Transactions of the Society for Modeling and Simulation International 88(2)
constitute the framework for the modeling processes in
the health care eld.
Our results rely heavily upon the assumptions
concerning the inclusion and assessment methodology.
Undoubtedly, some important papers from other
high-ranked academic journals may have been omitted.
An expansion of the scope of this survey could possibly
result in a shift of emphasis to other areas of problems
identied as more popular by the researchers and in a
revision of the methods used. The stochastic simulation
(DES with micro-simulation and MC), however, is
unquestioningly the most predominantly used tech-
nique in health care management and a signicant
number of models focus on improvements in organiza-
tion and delivery of care.
The fact that this study considered three model-
ing techniques may be construed as a drawback and
we propose that a further in-depth analysis of the meth-
ods applied would be of benet. We suggest including
other proles of classication of simulation
approaches, and in particular to consider hybrid
modeling techniques, which merge simulation with
other tools.
We further propose that future research could
involve a more exible classication in matching the
model to an application group. The methodology
used to divide the main groups into sub-groups within
the framework requires further discussion, as well as
formulation of guiding principles for applying one
model to several topic areas simultaneously. We plan
to continue our research in this direction.
Even though numerous examples of application
have been described in academic publications, simu-
lation models still have not been widely employed by
the health practitioners and policy makers. A system-
atic review conducted by Fone et al.7 found only a
few examples of successful implementation within the
health care industry. Brailsford174 identied and
discussed some existing barriers that contributed to
limiting the development of simulation models out-
side of the academic environment and described chal-
lenges faced by both academics and practitioners. The
aim of our survey was not to assess the value and
quality of simulation projects reported in literature.
Instead, we concentrated on the continued interest
in simulation modeling as applied in health care
issues. We tried to demonstrate that there exists
strong supporting evidence that the application of
simulation in the health care eld will continue to
grow and evolve.
Acknowledgments
We would like to thank the referees for their very valuable
comments.
Downloaded from sim.sagepub.com at St Petersburg State University on December 18, 2013
Funding
This work was partly supported by European Regional
Development Fund and the Polish Government
(Operational Programme Innovative Economy) under the
grant WROVASC Integrated Center of Cardiovascular
Medicine, which is being realized in the years 20072013.
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_
Bozena Mielczarek is an assistant professor of
Management Science at Wroclaw University of
Technology, Poland. She received her MSc in
Management Science and PhD in Economics from
Wroclaw University of Technology. Her research inter-
ests include simulation modeling methodologies, health
service research, decision support, and risk analysis.
Justyna Uzia1ko-Mydlikowska is presently working for
the National Health Fund in Wroclaw, Poland. She
received her MSc in Management Sciences and PhD
in Economics from Wroclaw University of
Technology. Her research interests include simulation
modeling methodologies and health service research.

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