The case for incorporating heterogeneity and malleability of patient screening behavior in simulation models

Simulation models have been used extensively to evaluate and aid in planning of health screening strategies in health care. In typical simulation models, patient screening behavior is often assumed as homogeneous (patient characteristics do not influence the probability of undergoing screening) and rigid (invariant with time, and not malleable by screening interventions), and modeled as such. However, patient screening behavior in reality is heterogeneous and malleable. Disregarding these realities affect the model functionality and modeling outcomes. We propose two general simulation model structures: one representing a typical existing simulation model and another representing a simulation model that incorporates heterogeneity and malleability of patient screening behavior. We then illustrate both model structures by implementing it in the case of Diabetic Retinopathy eye screening. Comparison of the two resulting models indicate that heterogeneity and malleability of patient screening behavior should be addressed in simulation models to improve model functionality and precision of outcome estimates.