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Discrete-Event Simulation Modeling in Healthcare: A Comprehensive Review

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Review

Discrete-Event Simulation Modeling in Healthcare:

A Comprehensive Review
Jesús Isaac Vázquez-Serrano 1, Rodrigo E. Peimbert-García 1,2,* and Leopoldo Eduardo Cárdenas-Barrón 1

1 School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon,
Mexico; [email protected] (J.I.V.-S.); [email protected] (L.E.C.-B.)
2 School of Engineering, Macquarie University, Sydney, NSW 2109, Australia

* Correspondence: [email protected]

Abstract: Discrete-event simulation (DES) is a stochastic modeling approach widely used to address
dynamic and complex systems, such as healthcare. In this review, academic databases were systemat-
ically searched to identify 231 papers focused on DES modeling in healthcare. These studies were
sorted by year, approach, healthcare setting, outcome, provenance, and software use. Among the sur-
veys, conceptual/theoretical studies, reviews, and case studies, it was found that almost two-thirds of
the theoretical articles discuss models that include DES along with other analytical techniques, such as
optimization and lean/six sigma, and one-third of the applications were carried out in more than one
healthcare setting, with emergency departments being the most popular. Moreover, half of the appli-
cations seek to improve time- and efficiency-related metrics, and one-third of all papers use hybrid
Citation: Vázquez-Serrano, J.I.; models. Finally, the most popular DES software is Arena and Simul8. Overall, there is an increasing
Peimbert-García, R.E.; trend towards using DES in healthcare to address issues at an operational level, yet less than 10% of
Cárdenas-Barrón, L.E. DES applications present actual implementations following the modeling stage. Thus, future re-
Discrete-Event Simulation Modeling search should focus on the implementation of the models to assess their impact on healthcare pro-
in Healthcare: A Comprehensive cesses, patients, and, possibly, their clinical value. Other areas are DES studies that emphasize their
Review. Int. J. Environ. Res. methodological formulation, as well as the development of frameworks for hybrid models.
Public Health 2021, 18, 12262.
https://doi.org/10.3390/ Keywords: discrete-event; simulation; modeling; healthcare; hospital; review; literature
ijerph182212262

Academic Editors:
Martin McNamara, Marie E. Ward
and Seán Paul Teeling
1. Introduction
Healthcare systems are largely adaptive human-based systems that involve both the
Received: 30 September 2021 utilization of limited physical facilities and resources, and complex interactions among
Accepted: 13 November 2021 different healthcare groups [1–3]. Since these healthcare systems are characterized by a
Published: 22 November 2021 high level of variability and uncertainty, they are not naturally easy to understand, de-
sign, and predict [4–7].
Publisher’s Note: MDPI stays neu- As healthcare systems continually evolve, achieving better quality of care while re-
tral with regard to jurisdictional
ducing costs is a global concern [7,8]. Thus, strategic, tactical, and operational decisions
claims in published maps and institu-
are made daily to evaluate and improve the efficiency and effectiveness of different
tional affiliations.
healthcare processes and services [3,7]. To foresee the impact of these decisions on the
system performance, healthcare providers need proper tools, such as simulation, so they
can effectively explore the alternative scenarios [1,9].
A simulation is an imitation of how the real-world system operates over time. This
Copyright: © 2021 by the authors. Li-
censee MDPI, Basel, Switzerland.
can be used to identify critical points and system bottlenecks, and to answer “what-if”
This article is an open access article
questions about real-world scenarios without any practical and/or financial implications
distributed under the terms and con- [10–12]. Simulations can estimate the consequences of different interventions in
ditions of the Creative Commons At- healthcare, allowing for the incorporation of behavioral aspects and personalized deci-
tribution (CC BY) license (https://cre- sions [7], as well as for identifying the optimal scenario according to some output criteria
ativecommons.org/licenses/by/4.0/). [13].

Int. J. Environ. Res. Public Health 2021, 18, 12262. https://doi.org/10.3390/ijerph182212262 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 12262 2 of 20

A simulation study requires the definition of a conceptual model; a representation of

a problem within a system that is derived from theory or observations [11,14,15]. This
conceptual representation should integrate different components, such as objectives, in-
puts, outputs, content, boundaries, assumptions, and simplifications [16,17]. Later, the
conceptual model is transferred into computer software that helps healthcare profession-
als to comprehend the relationship between the input and output variables of the real-
world system [1,18].
Discrete-event simulation (DES), also referred to as a time-to-event model, is ideal
for complex problems, such as healthcare ones [9,19]. DES is a computer-based operation
research technique that models different systems as networks of queues and activities [18]
in order to assess, predict, and optimize a proposed or existing system, where changes
occur at discrete epochs over time [8,20–22]. DES emerged from the manufacturing world,
wherein Tocher developed the first language in the late 1950s for constructing a model to
simulate a steel plant in the UK [7,23]. DES is often used to represent systems at an oper-
ational level, where transactions, processes, and the flow of individual entities, as well as
the variability, are important factors [4,24]. Hence, DES models use events and typical
quantities to imitate the observed behavior of the system by generating deterministic
quantities or stochastic distributions [3]. DES can capture a system´s behavior and inter-
connection effects, which result from the combinations of many random processes, cou-
pled with the system structure [25]. Conversely, developing a DES model can be time
consumingly (and costly), and it is heavily dependent on good quality data to inform the
system behavior [24]. Users should, thus, balance the benefits and challenges of using the
simulation approach.
The key concepts in DES are events, entities, attributes, and resources. An event is
something that happens in the environment at a certain point in time. In the healthcare
context, entities are self-contained objects that have attributes and consume resources
while experiencing events, e.g., patients, organs for transplant, medical records, etc.
[13,26]. Attributes are features or characteristics that are unique to an entity and can
change over time, such as age and disease history, which influence their route through the
simulation and the length of time between events [26]. Finally, resources are objects or
facilities that provide a service to a dynamic entity, for example, doctors, nurses, hospital
beds, operating rooms, physicians, etc. In addition, queues represent another important
concept in DES, as they occur when several entities compete for a specific constrained
resource, and they might have to wait until the resource is available. Each queue has its
own logic and rules, commonly called a “queue discipline” [7,13,17].
Building a DES model requires large amounts of quantitative numerical data [18]. It
also needs a set of logical statements that are expressed in a computable form to describe
how the entities change their state [27]. DES has been used in healthcare as a preferable
modeling technique, given its flexibility in responding to scale changes, the level of detail,
individual patient focus, stochastic factors affecting the system, the ease in changing the
model´s components, waiting for the time-related performance, the existence of queues,
and the visual representation of patient flows [17]. Although big data analysis is emerging
as a technique for data modeling and simulation, it presents more challenges in processes
subject to changing conditions and unexpected events [28].
Table 1 summarizes the characteristics of discrete-event simulation. While DES outputs
can be point estimates, as well as ranges of values, the experimental results can be measured
in terms of performance metrics, such as resource utilization, waiting times, the number of
entities in queues, and the throughput of services or products, among others [29].
As healthcare systems become more complex, in combination with stricter quality
demands, there is also a growing interest in the use of DES modeling in these settings,
exemplified by the increasing number of articles published in the literature every year
(period 1994–2021). Since more than 200 research articles are found in the literature, this
study conducts a comprehensive literature review to provide a wider perspective of the
DES capabilities presented in healthcare until 2021. This paper provides a deep and
Int. J. Environ. Res. Public Health 2021, 18, 12262 3 of 20

detailed categorization of the DES articles in healthcare that will help researchers to iden-
tify the DES trends (areas of application, outcomes, software used, contribution of articles
by country, and popular journals and publishers), and to identify opportunities for future
research through four elements: the key elements to formulating models, frameworks for
hybrid models, barriers for implementation, and measuring satisfaction and clinical value.
The remainder of the article is presented as follows: Section 2 presents the methodology,
including the search strategy, inclusion criteria, and review methodology. Section 3 pre-
sents the results and classification by year, approach, healthcare setting, outcome, prove-
nance, and software use. Section 4 discusses these results, and Section 5 provides the con-
clusions.

Table 1. Characteristics of discrete event simulation.

Scope: Operational, tactical

Purpose: Decisions: Optimizations, predictions, and comparisons
Perspective: Analytic, emphasis on detail complexity
Importance of variability: High
Importance of tracking individuals: High
Number of entities: Large
Control: Waiting (queues)
Relative timescale: Short
Resolution of models: Individual entities, attributes, decisions, and events
Data sources: Numeric with some critical elements
Lower boundary of technical prepa-
Qualitative workflow
ration:
Model elements: Physical, tangible, information
Model outputs: Prediction points, performance measurements
Arena, Simul8, FlexSim/FlexSim Healthcare, ProModel/MedModel, Simio, AnyLogic,
Tools:
TreeAge, ExtendSim

2. Methods
2.1. Search Strategy
The databases Springer, BioMed Central, ScienceDirect, Web of Science, Research
Gate, Wolters Kluwer, MDPI, Taylor & Francis, ProQuest, Wiley Online Library, Mary
Ann Liebert, IEEE, Scopus, Emerald, Sage, BMJ, and PubMed Central were systematically
searched to retrieve existing articles on DES applications in healthcare, until August 2021
when the last search was conducted. The key terms used to search included: “discrete
event”, “DES”, “simulation”, “hospital”, and “healthcare”, in the title, abstract, and/or
keywords. No restrictions related to year, approach, healthcare setting, outcome, country
of provenance, or software use were considered.

2.2. Paper Inclusion Criteria

The inclusion criteria in this review were narrowed down to research articles that
focus on DES in healthcare, including a range of studies from the exploration of theoretical
aspects up to practical applications. Publications regarding other operational research
techniques were excluded, but studies on hybrid DES models were included in this re-
search. Non-English-language literature, and other English-language articles published
outside peer-reviewed journals, such as conference papers, books, editor notes, etc., were
discarded. Following the retrieval of publications, 231 papers were considered in this
study. A total of 51.8% of the papers were retrieved from healthcare-related journals,
while the rest were retrieved from industrial-engineering-related journals. Figure 1 shows
the three-stage searching and sorting process that led to the research articles included in
this study.
Int. J. Environ. Res. Public Health 2021, 18, 12262 4 of 20

Figure 1. Inclusion and classification process of the review.

2.3. Review Methodology

The articles included in this review are divided into three taxonomy sections: (1) DES
application articles that report original research; (2) Theoretical/conceptual articles that
provide directions to explore problems or represent relations within DES models; and (3)
Review articles that structure and classify the existing literature on the topic. Survey pa-
pers were analyzed alongside review papers as they were very few, and they focused on
specific DES applications. Specific to the review papers included, only five studies focus
entirely on DES as a unique review topic, and the rest aim to analyze healthcare improve-
ments through diverse operations research techniques, DES being one of the approaches
mentioned [21,30–33].
The search identified a total of 170 DES applications in healthcare, followed by 48
theoretical/conceptual articles, and 13 review/survey studies. Further classification within
these main categories includes the approach, healthcare setting, outcome, country of prov-
enance, and software use. While healthcare setting, country, and software use were di-
rectly extracted from the papers, the approach and outcome required deeper analysis. The
review process also showed that approaches can vary, from unique DES applications up
to models combining DES along with Markov models, Monte Carlo simulation (MCS),
system dynamics (SD), agent-based simulation (ABS), optimization (Opt), mathematical
models (Math models), and lean/six sigma. Specific to the review and theoretical/concep-
tual papers, the empirical outcomes, defined after the analysis of the papers, are the de-
scriptions of the operational research techniques, the descriptions of the healthcare back-
grounds, and the frameworks. Likewise, possible outcomes for DES application papers
are:
 Time and efficiency;
 Financial and cost savings;
 Allocation of resources/schedule;
 Quality and defects;
 Patient health/safety.
Int. J. Environ. Res. Public Health 2021, 18, 12262 5 of 20

3. Results
This section is presented through the three taxonomies mentioned before: (1) Review
papers; (2) Theoretical/conceptual papers; and (3) DES application papers. Figure 2 pre-
sents the distribution of publications over the years.

Figure 2. Number of publications per year.

3.1. Review and Survey Papers

Review papers are characterized by the exploration and classification of DES devel-
opments in healthcare, and commonly utilize descriptive statistics and frequency counting.
DES-related reviews generally analyzed the general healthcare domain (80%), while the rest
analyzed applications on a specific area or application. Moreover, half of the paper-re-
viewed studies consider DES in combination with several other techniques. Table 2 presents
the complete set/approach classification and percentages of the review papers considered.
The main limitation of previous DES-related reviews in healthcare is the narrow
scope and contribution; some of them focus only on a specific taxonomy or study type,
while others do not consider hybrid models, or they divide a shallow classification into
fewer categories. Finally, the current directions for future research are very limited since
the research was conducted some time ago.

Table 2. Discrete-event simulation review papers in the literature.

Setting/Approach DES DES + Markov DES + SD or ABS DES + Others Total

General Healthcare [30–35] [36] [37] [38,39] 10
Emergency Unit [40] 1
Medical Center [21] [41] 2
Total 7 1 2 3 13
Survey papers: [34–41]

3.2. Theoretical/Conceptual Papers

The aim of the theoretical/conceptual papers is mainly to provide support for per-
forming practical DES applications in healthcare. Developing DES theory and the con-
cepts within healthcare are focused on emergency departments in 13% of the cases, and
on the general healthcare domain in 36% of the cases, as per Table 3. Frameworks for the
DES applications are provided in 44% of the studies, and the use of DES hybrid models is
discussed in 63% of these.
Int. J. Environ. Res. Public Health 2021, 18, 12262 6 of 20

Table 3. Discrete-event simulation theoretical and conceptual papers in the literature.

Setting/ DES + Optimization DES + Lean or DES + SD or ABS or

DES DES + Others Total %
Approach or Math Model Six Sigma Monte Carlo
General Healthcare [42–45] [20] [3,15,18,43,46–49] [26,50–52] 17 36
Emergency Unit [53–56] [57] [9] 6 13
Intensive Unit [58] 1 2
Operating Room [22] 1 2
Pediatric [13] 1 2
Therapy [24,59] 2 4
Psychiatry [60] 1 2
Patient State [61–64] [65] 5 10
Medical Center [66–70] [2,71,72] [73] [7,17,74–76] 14 29
Total 18 5 2 18 5 48
% 38 10 4 38 10 100

3.3. DES Applications Papers

3.3.1. Approach
All 170 DES models were validated, and different “what-if” scenarios have been
tested with each model. However, less than 10% have carried out implementation to im-
prove the system’s performance (it was considered that a study had an actual implemen-
tation if that is stated in the paper, or if evidence of implementation is shown). On the
other hand, one-third of the DES applications are complemented with another technique,
such as operations research, so they can provide a wider range of characteristics to solve
operational healthcare problems. Other hybrid models combine DES with different simu-
lation approaches, such as system dynamics (SD), agent-based simulation (ABS), and
Monte Carlo simulation (MCS), in order to complement and enlarge the scope, purpose,
and perspective of the simulation. Inferential statistics are also considered and used to
infer and make concise predictions about the indicators used in the simulation. Moreover,
the soft systems methodology (SSM) is also incorporated to justify changes and/or im-
provements in organizational systems. Other approaches include optimization models to
mathematically describe those factors that are not explained only with probability distri-
butions, and lean/six sigma, and/or mapping techniques to improve the system under
study. Figure 3 shows the percentages of the approaches used in the studies.

Figure 3. Approaches of applied research papers.

Int. J. Environ. Res. Public Health 2021, 18, 12262 7 of 20

3.3.2. Setting and Outcomes

A total of 38.9% of the DES application studies were conducted in hospital and med-
ical centers, while 21.8% specifically focused on emergency departments, and 13% on the
patient clinical conditions. Moreover, half of the outcomes reported in these studies are
related to time and efficiency, 21.2% to the allocation of resources/schedules, and 12.3%
on financial and cost savings. Table 4 presents the classification of papers based on the
healthcare setting under study and the corresponding outcomes.

Table 4. Discrete-event simulation publications classified by setting and outcome.

Financial and Cost Allocation of Re-

Setting/Outcome Time and Efficiency Public Health Others Total %
Savings sources/Schedule
Clinic [77,78] [79,80] 4 2.3
Emergency Unit [10,11,81–104] [105–113] [1,114] 37 21.8
Intensive Unit [115–117] [118] 4 2.4
Laboratory [16] 1 0.5
Nursing [119] [8] 2 1.2
Oncology [120,121] [122,123] 4 2.4
Operating Room [124–126] [127,128] 5 3
Orthopedic [129–131] [132] [6,133] 6 3.6
Pathology [134] 1 0.5
Pediatric [135] 1 0.5
Therapy [136,137] 2 1.2
Pharmacy [138,139] 2 1.2
Radiology [140–144] 5 3
Support Areas [145] [146–148] [149] 5 3
Dental Area [150] 1 0.5
Mammography [151] 1 0.5
Patient State [152] [19,153–163] [164–172] 22 13
Medical Device [173] 1 0.5
Medical Center [12,14,22,27,174–202] [203–206] [207–223] [25,224–228] [229–234] 66 38.9
Total 84 21 36 19 10 170
% 49.4 12.3 21.2 11.2 5.9 100

3.3.3. Journals, Publishers, and Countries

The journals with the most DES publications in healthcare are Health Care Management
Science (6% of papers. Rank 2020: SJR 0.9, Q1; CiteScore Scopus 4.6), the Journal of the Opera-
tional Research Society (5% of papers. Rank 2020: SJR 0.753, Q2; CiteScore Scopus 4.1), and the
Journal of Simulation (4%. Rank 2020: SJR 0.294, Q3; CiteScore Scopus 3.5). Meanwhile, the
top publishers are Elsevier (20%), Springer (20%), and Taylor & Francis (10%). Table 5 pre-
sents the top ten publications by the number of citations, as retrieved from Scopus in Octo-
ber 2021.
Concerning countries where these DES-related studies were carried out, 26% of the
publications proceeded from authors with affiliations in the US, 19% from the UK, and
12% from Canada. In contrast, the top developing countries, such as Brazil, Egypt, and
Malaysia, have each contributed to 4% of the literature. Table 6 shows the main publishers
and countries in the literature. Before 2012, almost 50% of the studies were published by
institutions affiliated with the U.S. and the U.K. As of 2012, the application of DES in the
health sector has become widespread throughout the world.
Int. J. Environ. Res. Public Health 2021, 18, 12262 8 of 20

Table 5. Top DES publications by number of citations.

Number Publication Average Citations per Year

Article Journal Publisher
of Citations Year (until 2021)
[182] Health Care Management Science Springer 117 2006 7.8
[131] Health Care Management Science Springer 113 2011 11.3
[204] Health Economics Wiley 100 2003 5.6
[233] Health Care Management Science Springer 69 2002 3.6
[25] European Journal of Operational Research Elsevier 67 2014 9.6
[149] Health Care Management Science Springer 66 2007 4.7
[184] Production and Operations Management Wiley 57 2011 5.7
[125] Health Care Management Science Springer 55 2010 5.0
[87] Simulation Modelling Practice and Theory Elsevier 50 2015 8.3
[121] European Journal of Operational Research Elsevier 49 2016 9.8

Table 6. DES publications classified by main publishers and countries.

Country/Publisher Springer Elsevier Taylor & Francis Palgrave Others Total %

US 11 8 5 0 20 44 25.9
UK 5 4 4 9 11 33 19.4
Canada 4 4 3 1 9 21 12.4
Others 14 18 6 3 31 72 42.3
Total 34 34 18 13 71 170
% 20 20 10.5 7.7 41.8 100

3.3.4. Software Use

Specialized DES software is used in 88% of the articles, whereas the complementary 12%
utilized low-level simulation scripting languages, such as Python, or intermediate-level sim-
ulation tools that incorporated low-level scripting with enhanced graphic interfaces, such as
MATLAB (MathWorks, Natick, MA, US) and Visual Object Net++ (Dr. Reiner Drath, Illemnau,
Germany) [235]. The reason why specialized DES software is used the most is that it provides
the modeler with an environment that, in comparison to scripting languages, allows for the
creation of models in less time and with less complexity. The most common software is Arena
(Rockwell Automation, Milwaukee, WI, US) (35%) and Simul8 (Simul8 Corporation, Boston,
MA, US) (21%). Within articles presenting hybrid models, around half use a specialized DES
software, while Arena remains the most used software (22%). However, 32% of the publica-
tions do not mention the software utilized.

4. Discussion
The popularity of DES in healthcare is notably increasing, as almost 40% of the papers
were published in the last three years. This is due to its ability to include high levels of
detail and the ease-of-modeling medical processes using stochastic factors. Lately, DES is
being applied in emergency departments, where short lead times and the efficient use of
resources are key to operating. Similarly, the clinical analysis of entities (patient clinical
condition) is emerging as a broader perspective from which to apply DES from a strictly
medical perspective (13% of the application papers). The simulation of the clinical condi-
tion of patients plays a critical role in reducing treatment costs, improving the efficiency
in the use of medicines, and analyzing the medical evolution of patients out of acute care.
Even though three countries concentrate 57.7% of the publications addressing DES
in healthcare (the US, the UK, and Canada), the fundamental tools for engaging the stake-
holders in healthcare systems worldwide in the development and application of DES are
the virtual interaction elements, such as user interfaces. In addition, the software used to
carry out simulations plays an essential role in the DES involvement in healthcare. A spe-
cific and flexible DES software has a higher probability of adapting to the healthcare
Int. J. Environ. Res. Public Health 2021, 18, 12262 9 of 20

stakeholders’ needs. This is the reason why only 12% of the papers utilize low-level sim-
ulation scripting languages.
Several elements have caused the impact of DES on healthcare improvement to be
questioned, such as the limited scope of the studies found in the literature, and the con-
textual factors that make healthcare improvement complex. Thus, this discussion is pre-
sented through four main areas that present opportunities for further research: key ele-
ments to formulate models, frameworks for hybrid models, barriers for implementation,
and measuring satisfaction and clinical value. Figure 4 presents the perspective of DES in
healthcare considering these elements.

Figure 4. Holistic perspective for DES applications in healthcare.

4.1. Key Elements to Formulate Models

The formulation of a model plays a critical role in simulation research, as it ensures
that the modeler depicts the right theoretical state and focuses the impact on the root
causes of the problem. A good formulation should consider five key elements: stakeholder
engagement, definition, credibility, utility, and feasibility [8,53,65,114]. When theory and
applications are supported by a proper formulation, publications tend to be beneficial for
both researchers and system stakeholders.
Despite some theoretical publications addressing stakeholder engagement, this is not
usually considered in DES applications. Engaging all stakeholders is key to formulating a
simulation project [53], particularly in the healthcare context, where there is a plurality of
stakeholder opinions, objectives, and power distributions [114]. In conjunction with stake-
holders, modelers should define the causes of the problem, the main goal sought, and the
internal and external influences that intervene in defining that goal [8]. In alliance with
the system’s stakeholders, it should be defined whether the conceptual model is suffi-
ciently accurate for the purpose at hand (credibility), if it assists decisionmakers in the
problem situation (utility), and if any project limitations, such as time, resources, and/or
data availability, are considered (feasibility) [65]. Then, conducting more studies built
over these formulation elements are required.

4.2. Frameworks for Hybrid Models

Given that healthcare systems are complex, there are a plethora of problems that can-
not be analyzed using a single method. Hybrid approaches provide a more realistic pic-
ture of complex systems with fewer assumptions and less complexity [9], which, in turn,
allows for addressing a larger range of modeling questions [74]. There is specialized soft-
ware, such as Simul8, AnyLogic, and Arena that allow the modeler to develop hybrid
simulation models in the same interface/environment, as developed in the research pre-
sented in [236,237]. However, in the healthcare context, combining simulation techniques is
Int. J. Environ. Res. Public Health 2021, 18, 12262 10 of 20

not enough; even when this review has shown that hybrid DES models (mathematical mod-
els, statistics, improvement methodologies, or mapping techniques) have been broadly ap-
plied over the last years, there are no frameworks available that can serve as the foundation
for successful modeling and implementation. It is important to have this kind of structure
that can guide the modeler in developing more robust hybrid models. Additionally, a frame-
work should provide support for identifying the object or system (What), the purpose
(Why), and the methodology (How) [74]. Moreover, it should allow for the recognition of
the correct approach/technique for collecting data and evaluating the long-term effects and
outcomes [9].

4.3. Barriers for Implementation

A proper formulation does not guarantee that DES models will be implemented. Fur-
thermore, transformation efforts never come without challenges [197]. Although simula-
tion is widely reported upon in healthcare, it is not clear whether there is an actual imple-
mentation and impact in the real health system [23,238]. It was found that less than 10%
of studies showed evidence of implementation. Most of the DES models applied to
healthcare settings are led by academics, mainly for research purposes, and they have a
limited impact on the potential performance of the systems [23]. Two major barriers to
implementation have been identified in this study. First, there is the cultural side, as
healthcare professionals (e.g., doctors and nurses) respond to pressure and system modi-
fications by changing their performance and behavior [9]. In conjunction with changes,
diversity across entities causes a lack of acceptance and fear regarding information and
confidentiality [229]. Second, infrastructure plays a critical role. Difficulty in accessing
enough quality data, system failures, and changes in work processes, security, and pri-
vacy, all are critical barriers to implementing models [229]. In addition, other financial
constraints could undermine research.
Because of the diversity of health systems, no panacea for implementation exists.
However, future research should reach to the models’ implementations and follow
through after the intervention [29] in order to evaluate the long-term effects. This would
convince service providers and clinicians that simulation can make a critical contribution
[46].

4.4. Measuring Satisfaction and Clinical Value

Most DES applications in healthcare focus on improving direct metrics, such as vol-
ume, efficiency, and occupancy rates, whereas after-implementation metrics related to pa-
tient satisfaction and value are more difficult and less common. High levels of value and
patient satisfaction are associated with better outcomes, given that satisfied patients are
more likely to adhere to treatment. Conversely, low patient satisfaction affects treatment
compliance, including return visit rates [22]. Thus, measuring these levels is a challenging
task [132], and developing methods/techniques alongside surveys and questionaries to
measure them represents a gap in the advances of DES applications in healthcare [230].

5. Conclusions
DES is a stochastic approach that is becoming more popular. This is reflected in the
growing number of research articles that are focused on DES in healthcare. A descriptive
analysis of DES publications in healthcare was conducted in this study to identify both cur-
rent trends in research and directions for future research. The findings show a tendency to
use this approach within emergency departments, patient clinical conditions, and medical
centers seeking to allocate resources and improve times and efficiency. The results also in-
dicate that the main issues addressed through DES are related to operations, where there is
a need for high levels of efficiency and financial savings. The US, the UK, and Canada are
the top countries that continually look towards improving their healthcare systems, as per
Table 5. It was also found that the most popular DES software for the studies is Arena.
Int. J. Environ. Res. Public Health 2021, 18, 12262 11 of 20

The large number of papers considered for this review (231) have shown the versa-
tility of the DES approach, as well as the broad adoption of operational research tech-
niques within some healthcare systems. Even though 231 papers is a large number, it rep-
resents a small proportion of the papers presenting analytical studies in healthcare.
Healthcare is an area where researchers focus on the application of operations research
techniques; however, DES is not being applied as much as lean/six sigma and other opti-
mization techniques. Specific to hybrid approaches, the combination of several techniques
can create a solid analytical approach that addresses the weaknesses of DES, such as stra-
tegic alignment and stakeholder behavior, as well as integrated levels.
DES models formulated in future research need to tackle two elements: proper and
correct formulation, and the incorporation of the behavior of healthcare staff, in order to
defeat cultural obstacles. Furthermore, researchers and professionals should define key
infrastructural and financial capacities. Finally, the evaluation of the long-term effects,
along with the publication of successful implementations following DES modeling, are
key opportunities that need to be addressed in future DES-related research in healthcare.

Author Contributions: Conceptualization, J.I.V.-S. and R.E.P.-G.; methodology, J.I.V.-S. and R.E.P.-
G.; validation, R.E.P.-G.; formal analysis, J.I.V.-S.; investigation, J.I.V.-S.; resources, R.E.P.-G.; data
curation, J.I.V.-S.; writing—original draft preparation, J.I.V.-S.; writing—review and editing, J.I.V.-
S., R.E.P.-G. and L.E.C.-B.; visualization, L.E.C.-B.; supervision, R.E.P.-G.; project administration,
J.I.V.-S. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflicts of interest.

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