Guideline recommendations for treatment of patients with inflammatory bowel diseases are not implemented in clinical practice—results of a non-representative survey

  • Lea I. Kredel
  • Oliver Schneidereit
  • Jörg C. Hoffmann
  • Britta Siegmund
  • Jan C. PreißEmail author
Original Article



There is a growing evidence for over-, under-, or misuse of health care in patients with inflammatory bowel disease. Most studies looked at treatment variability or used quality measures, which mostly capture supportive interventions rather than treatment of IBD in itself. We aimed to evaluate if current recommendations in clinical practice guidelines regarding the medical treatment of patients with inflammatory bowel diseases are being followed in Germany.


A questionnaire was sent to 1901 patients insured with two large German statutory sickness funds and an ICD 10 diagnosis of Crohn’s disease (CD) or ulcerative colitis (UC). The questionnaire asked about drug treatment, indications for drug treatment, provision of surveillance endoscopies in ulcerative colitis patients, and smoking status in Crohn’s disease patients.


Out of 460 evaluable patients, 62.4% of UC patients and 53.9% of CD patients were treated with mesalamine according to guidelines, 91.3% of all patients were treated with glucocorticoids according to guideline recommendations, while only 75.6% received recommended immunosuppressive treatment. Of UC patients, 94.5% had surveillance colonoscopies at the recommended interval and 58.8% of CD patients were non-smokers. No predictor for overall treatment according to guidelines could be found while being of age older than 60 or being treated outside of a dedicated IBD clinic was associated with less immunosuppressive treatment.


A large proportion of patients with IBD do not receive drug treatment in accordance with clinical practice guidelines. Quality improvement measures are much needed.


Survey Health services Treatment Clinical practice guidelines Inflammatory bowel diseases 



We would like to acknowledge the support by the three involved sickness funds, AOK Nordost (Katrin Peise), TK (Christine Vietor), and AOK Rheinland/Hamburg (Markus Feger) as well as Annegret Schönberg for secretarial assistance.

Funding agency

This study was partially funded by the Ministry of Education and Research (Bundesministerium für Bildung und Forschung), Germany, through the Kompetenznetz Entzündliche Darmerkrankungen (Grant Number 01 GI 0486).

Compliance with ethical standards

Conflict of interest

JCH served as consultant for Astra, Falk, Hexal, Janssen, Pfizer, Steigerwald, and Takeda, and received lecture fees from Falk, Janssen, MSD, Pfizer, and Takeda. BS received a research grant from Pfizer, served as consultant for Falk, Janssen, MSD, Abbvie, Celgene, Lilly, Takeda, Pfizer, and Hospira and received lecture fees from Abbvie, Falk, Ferring, Janssen, MSD, Merck, and Takeda; all money went to the Charité-Universitätsmedizin Berlin, Germany. JCP served as a consultant for MSD, Pfizer, Takeda, and Biogen and received lecture fees from Vifor, Falk, Janssen, Abbvie, Pfizer, Vifor, MSD, and Takeda.

Ethical approval

The local ethics board approved the protocol. All patient-related data were anonymized after open questions had been resolved in responders who provided their contact information.

Informed consent

Informed consent was assumed if patients sent in their questionnaire. The local data protection commissioner approved the protocol.


  1. 1.
    Dignass A, Preiß JC, Aust DE, Autschbach F, Ballauff A, Barretton G, Bokemeyer B, Fichtner-Feigl S, Hagel S, Herrlinger K, Jantschek G, Kroesen A, Kruis W, Kucharzik T, Langhorst J, Reinshagen M, Rogler G, Schleiermacher D, Schmidt C, Schreiber S, Schulze H, Stange E, Zeitz M, Hoffmann J, Stallmach A (2011) Aktualisierte Leitlinie zur Diagnostik und Therapie der Colitis ulcerosa 2011 - Ergebnisse einer Evidenzbasierten Konsensuskonferenz. Z Gastroenterol 49:1276–1341. CrossRefPubMedGoogle Scholar
  2. 2.
    Preiß JC, Bokemeyer B, Buhr HJ, Dignaß A, Häuser W, Hartmann F, Herrlinger KR, Kaltz B, Kienle P, Kruis W, Kucharzik T, Langhorst J, Schreiber S, Siegmund B, Stallmach A, Stange EF, Stein J, Hoffmann JC, German Society of Gastroenterology (2014) Aktualisierte S3-Leitlinie - “Diagnostik und Therapie des Morbus Crohn” 2014. Z Gastroenterol 52:1431–1484. CrossRefPubMedGoogle Scholar
  3. 3.
    Magro F, Gionchetti P, Eliakim R, Ardizzone S, Armuzzi A, Barreiro-de Acosta M, Burisch J, Gecse KB, Hart AL, Hindryckx P, Langner C, Limdi JK, Pellino G, Zagórowicz E, Raine T, Harbord M, Rieder F, for the European Crohn’s and Colitis Organisation [ECCO] (2017) Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, Cancer surveillance, surgery, and Ileo-anal pouch disorders. J Crohns Colitis 11:649–670. CrossRefPubMedGoogle Scholar
  4. 4.
    Harbord M, Eliakim R, Bettenworth D, Karmiris K, Katsanos K, Kopylov U, Kucharzik T, Molnár T, Raine T, Sebastian S, de Sousa HT, Dignass A, Carbonnel F, for the European Crohn’s and Colitis Organisation [ECCO] (2017) Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 2: current management. J Crohns Colitis 11:769–784. CrossRefPubMedGoogle Scholar
  5. 5.
    Gomollón F, Dignass A, Annese V, Tilg H, van Assche G, Lindsay JO, Peyrin-Biroulet L, Cullen GJ, Daperno M, Kucharzik T, Rieder F, Almer S, Armuzzi A, Harbord M, Langhorst J, Sans M, Chowers Y, Fiorino G, Juillerat P, Mantzaris GJ, Rizzello F, Vavricka S, Gionchetti P, on behalf of ECCO (2017) 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn’s Disease 2016: part 1: diagnosis and medical management. J Crohns Colitis 11:3–25. CrossRefPubMedGoogle Scholar
  6. 6.
    Gionchetti P, Dignass A, Danese S, Magro Dias FJ, Rogler G, Lakatos PL, Adamina M, Ardizzone S, Buskens CJ, Sebastian S, Laureti S, Sampietro GM, Vucelic B, van der Woude CJ, Barreiro-de Acosta M, Maaser C, Portela F, Vavricka SR, Gomollón F, on behalf of ECCO (2017) 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn’s Disease 2016: part 2: surgical management and special situations. J Crohns Colitis 11:135–149. CrossRefPubMedGoogle Scholar
  7. 7.
    Vavricka SR, Spigaglia SM, Rogler G, Pittet V, Michetti P, Felley C, Mottet C, Braegger CP, Rogler D, Straumann A, Bauerfeind P, Fried M, Schoepfer AM (2012) Systematic evaluation of risk factors for diagnostic delay in inflammatory bowel disease. Inflamm Bowel Dis 18:496–505. CrossRefPubMedGoogle Scholar
  8. 8.
    Mawdsley JED, Irving PM, Makins RJ, Rampton DS (2006) Optimizing quality of outpatient care for patients with inflammatory bowel disease: the importance of specialist clinics. Eur J Gastroenterol Hepatol 18:249–253CrossRefPubMedGoogle Scholar
  9. 9.
    Kirchgatterer A, Wenzl HH, Aschl G, Hinterreiter M, Stadler B, Hinterleitner TA, Petritsch W, Knoflach P (2002) Examination, prevention and treatment of osteoporosis in patients with inflammatory bowel disease: recommendations and reality. Acta Med Austriaca 29:120–123CrossRefPubMedGoogle Scholar
  10. 10.
    Sam JJ, Bernstein CN, Razik R, Thanabalan R, Nguyen GC (2013) Physicians’ perceptions of risks and practices in venous thromboembolism prophylaxis in inflammatory bowel disease. Dig Dis Sci 58:46–52. CrossRefPubMedGoogle Scholar
  11. 11.
    Tinsley A, Naymagon S, Trindade AJ, Sachar DB, Sands BE, Ullman TA (2013) A survey of current practice of venous thromboembolism prophylaxis in hospitalized inflammatory bowel disease patients in the United States. J Clin Gastroenterol 47:e1–e6. CrossRefPubMedGoogle Scholar
  12. 12.
    Nguyen GC, Murthy SK, Bressler B, Lam MCW, Alali A, Toumi A, Reinglas J, Rampersad A, Weizman AV, Afif W (2017) Quality of care and outcomes among hospitalized inflammatory bowel disease patients: a multicenter retrospective study. Inflamm Bowel Dis 23:695–701. CrossRefPubMedGoogle Scholar
  13. 13.
    Selby L, Kane S, Wilson J, Balla P, Riff B, Bingcang C, Hoellein A, Pande S, de Villiers WJS (2008) Receipt of preventive health services by IBD patients is significantly lower than by primary care patients. Inflamm Bowel Dis 14:253–258. CrossRefPubMedGoogle Scholar
  14. 14.
    Long MD, Porter CQ, Sandler RS, Kappelman MD (2009) Suboptimal rates of cervical testing among women with inflammatory bowel disease. Clin Gastroenterol Hepatol 7:549–553. CrossRefPubMedGoogle Scholar
  15. 15.
    Chevaux J-B, Nani A, Oussalah A, Venard V, Bensenane M, Belle A, Gueant JL, Bigard MA, Bronowicki JP, Peyrin-Biroulet L (2010) Prevalence of hepatitis B and C and risk factors for nonvaccination in inflammatory bowel disease patients in Northeast France. Inflamm Bowel Dis 16:916–924. CrossRefPubMedGoogle Scholar
  16. 16.
    Teich N, Klugmann T, Tiedemann A, Holler B, Mössner J, Liebetrau A, Schiefke I (2011) Vaccination coverage in immunosuppressed patients: results of a regional health services research study. Dtsch Arztebl Int 108:105–111. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Spiegel BMR, Ho W, Esrailian E, Targan S, Higgins PDR, Siegel CA, Dubinsky M, Melmed GY (2009) Controversies in ulcerative colitis: a survey comparing decision making of experts versus community gastroenterologists. Clin Gastroenterol Hepatol 7:168–174, 174.e1. CrossRefPubMedGoogle Scholar
  18. 18.
    Hinojosa J, Gisbert JP, Gomollón F, López San Román A (2012) Adherence of gastroenterologists to European Crohn’s and colitis organisation consensus on Crohn’s disease: a real-life survey in Spain. J Crohns Colitis 6:763–770. CrossRefPubMedGoogle Scholar
  19. 19.
    Caldera F, Saha S, Wald A, Cooley DM, Zhao YQ, Li Z, Bartels CM (2016) Comparing guideline-based care quality for inflammatory bowel disease and rheumatoid arthritis patients within a medical home. Expert Rev Gastroenterol Hepatol 10:759–766. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Sawczenko A, Lynn R, Sandhu BK (2003) Variations in initial assessment and management of inflammatory bowel disease across Great Britain and Ireland. Arch Dis Child 88:990–994CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Blumenstein I, Bock H, Weber C, Rambow A, Tacke W, Kihn R, Pfaff R, Orlemann S, Schaeffer R, Schröder O, Digna A, Hartmann F, Stein J (2008) Health care and cost of medication for inflammatory bowel disease in the Rhein-Main region, Germany: a multicenter, prospective, internet-based study. Inflamm Bowel Dis 14:53–60. CrossRefPubMedGoogle Scholar
  22. 22.
    Magro F, Barreiro-de Acosta M, Lago P, Carpio D, Cotter J, Echarri A, Gonçalves R, Pereira S, Carvalho L, Lorenzo A, Barros L, Castro J, Dias JA, Rodrigues S, Portela F, Dias C, da Costa-Pereira A, EIGA, GEDII (2010) Clinical practice in Crohn’s disease in bordering regions of two countries: different medical options, distinct surgical events. J Crohns Colitis 4:301–311. CrossRefPubMedGoogle Scholar
  23. 23.
    Ananthakrishnan AN, Kwon J, Raffals L, Sands B, Stenson WF, McGovern D, Kwon JH, Rheaume RL, Sandler RS (2015) Variation in treatment of patients with inflammatory bowel diseases at major referral centers in the United States. Clin Gastroenterol Hepatol 13:1197–1200. CrossRefPubMedGoogle Scholar
  24. 24.
    Hilsden RJ, Verhoef MJ, Best A, Pocobelli G (2003) A national survey on the patterns of treatment of inflammatory bowel disease in Canada. BMC Gastroenterol 3:10. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Blumenstein I, Bock H, Zosel C, Dignass A, Hartmann F, Zeuzem S, Stein J, Schroeder O (2009) Gibt es geschlechtsspezifische Behandlungsunterschiede bei Patienten mit chronisch entzündlichen Darmerkrankungen? Eine Subgruppenanalyse einer prospektiven, multizentrischen, online-basierten Studie. Z Gastroenterol 47:1045–1051. CrossRefPubMedGoogle Scholar
  26. 26.
    Blumenstein I, Herrmann E, Filmann N, Zosel C, Tacke W, Bock H, Dignaß A, Hartmann F, Zeuzem S, Stein J, Schröder O (2011) Female patients suffering from inflammatory bowel diseases are treated less frequently with immunosuppressive medication and have a higher disease activity: a subgroup analysis of a large multi-centre, prospective, internet-based study. J Crohns Colitis 5:203–210. CrossRefPubMedGoogle Scholar
  27. 27.
    Nguyen GC, LaVeist TA, Harris ML et al (2010) Racial disparities in utilization of specialist care and medications in inflammatory bowel disease. Am J Gastroenterol 105:2202–2208. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Donovan M, Lunney K, Carter-Pokras O, Cross RK (2007) Prescribing patterns and awareness of adverse effects of infliximab: a health survey of gastroenterologists. Dig Dis Sci 52:1798–1805. CrossRefPubMedGoogle Scholar
  29. 29.
    Farraye FA, Waye JD, Moscandrew M, Heeren TC, Odze RD (2007) Variability in the diagnosis and management of adenoma-like and non-adenoma-like dysplasia-associated lesions or masses in inflammatory bowel disease: an internet-based study. Gastrointest Endosc 66:519–529. CrossRefPubMedGoogle Scholar
  30. 30.
    Yeung JH, Goodman KJ, Fedorak RN (2012) Inadequate knowledge of immunization guidelines: a missed opportunity for preventing infection in immunocompromised IBD patients. Inflamm Bowel Dis 18:34–40. CrossRefPubMedGoogle Scholar
  31. 31.
    Wasan SK, Coukos JA, Farraye FA (2011) Vaccinating the inflammatory bowel disease patient: deficiencies in gastroenterologists knowledge. Inflamm Bowel Dis 17:2536–2540. CrossRefPubMedGoogle Scholar
  32. 32.
    Adams AS, Soumerai SB, Lomas J, Ross-Degnan D (1999) Evidence of self-report bias in assessing adherence to guidelines. Int J Qual Health Care 11:187–192CrossRefPubMedGoogle Scholar
  33. 33.
    Walsh AJ, Weltman M, Burger D, Vivekanandarajah S, Connor S, Howlett M, Radford-Smith G, Selby W, Veillard AS, Grimm MC, Travis SPL, Lawrance IC (2013) Implementing guidelines on the prevention of opportunistic infections in inflammatory bowel disease. J Crohns Colitis 7:e449–e456. CrossRefPubMedGoogle Scholar
  34. 34.
    Stange EF, Schreiber S, Fölsch UR, von Herbay A, Schölmerich J, Hoffmann J, Zeitz M, Fleig WE, Buhr HJ, Kroesen AJ, Moser G, Matthes H, Adler G, Reinshagen M, Stein J, German Society for Digestive and Metabolic Diseases (2003) Diagnostik und Therapie des M. Crohn – Ergebnisse einer evidenzbasierten konsensuskonferenz der Deutschen Gesellschaft für Verdauungs-und Stoffwechselkrankheiten. Z Gastroenterol 41:19–20. CrossRefPubMedGoogle Scholar
  35. 35.
    Hoffmann JC, Zeitz M, Bischoff SC, Brambs HJ, Bruch HP, Buhr HJ, Dignaß A, Fischer I, Fleig W, Fölsch UR, Herrlinger K, Höhne W, Jantschek G, Kaltz B, Keller KM, Knebel U, Kroesen AJ, Kruis W, Matthes H, Moser G, Mundt S, Pox C, Reinshagen M, Reißmann A, Riemann J, Rogler G, Schmiegel W, Schölmerich J, Schreiber S, Schwandner O, Selbmann HK, Stange EF, Utzig M, Wittekind C (2004) Diagnostik und Therapie der Colitis Ulcerosa: Ergebnisse einer evidenzbasierten Konsensuskonferenz der Deutschen Gesellschaft für Verdauungs- und Stoffwechselerkrankungen zusammen mit dem Kompetenznetz chronisch entzündliche Darmerkrankungen. Z Gastroenterol 42:979–983CrossRefPubMedGoogle Scholar
  36. 36.
    Travis SP, Stange EF, Lemann M et al (2006) European evidence based consensus on the diagnosis and management of Crohn’s disease: current management. Gut 55(Suppl 1):i16–i35CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Stange EF, Travis SP, Vermeire S, Beglinger C, Kupcinkas L, Geboes K, Barakauskiene A, Villanacci V, von Herbay A, Warren BF, Gasche C, Tilg H, Schreiber SW, Schölmerich J, Reinisch W, European Crohn’s and Colitis Organisation (2006) European evidence based consensus on the diagnosis and management of Crohn’s disease: definitions and diagnosis. Gut 55(Suppl 1):i1–i15CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Caprilli R, Gassull MA, Escher JC, Moser G, Munkholm P, Forbes A, Hommes DW, Lochs H, Angelucci E, Cocco A, Vucelic B, Hildebrand H, Kolacek S, Riis L, Lukas M, de Franchis R, Hamilton M, Jantschek G, Michetti P, O’Morain C, Anwar MM, Freitas JL, Mouzas IA, Baert F, Mitchell R, Hawkey CJ, European Crohn’s and Colitis Organisation (2006) European evidence based consensus on the diagnosis and management of Crohn’s disease: special situations. Gut 55(Suppl 1):i36–i58CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Stange EF, Travis SPL, Vermeire S, Reinisch W, Geboes K, Barakauskiene A, Feakins R, Fléjou JF, Herfarth H, Hommes DW, Kupcinskas L, Lakatos PL, Mantzaris GJ, Schreiber S, Villanacci V, Warren BF, European Crohn’s and Colitis Organisation (ECCO) (2008) European evidence-based consensus on the diagnosis and management of ulcerative colitis: definitions and diagnosis. J Crohns Colitis 2:1–23. CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Travis SPL, Stange EF, Lemann M et al (2008) European evidence-based consensus on the management of ulcerative colitis: current management. J Crohns Colitis 2:24–62. CrossRefPubMedGoogle Scholar
  41. 41.
    Biancone L, Michetti P, Travis SPL, Escher JC, Moser G, Forbes A, Hoffmann JC, Dignass A, Gionchetti P, Jantschek G, Kiesslich R, Kolacek S, Mitchell R, Panes J, Soderholm J, Vucelic B, Stange E, European Crohn’s and Colitis Organisation (ECCO) (2008) European evidence-based consensus on the management of ulcerative colitis: special situations. J Crohns Colitis 2:63–92. CrossRefPubMedGoogle Scholar
  42. 42.
    Loftus EV (2004) Clinical epidemiology of inflammatory bowel disease: incidence, prevalence, and environmental influences. Gastroenterology 126:1504–1517. CrossRefPubMedGoogle Scholar
  43. 43.
    Colombel J-F, Panaccione R, Bossuyt P, Lukas M, Baert F, Vaňásek T, Danalioglu A, Novacek G, Armuzzi A, Hébuterne X, Travis S, Danese S, Reinisch W, Sandborn WJ, Rutgeerts P, Hommes D, Schreiber S, Neimark E, Huang B, Zhou Q, Mendez P, Petersson J, Wallace K, Robinson AM, Thakkar RB, D'Haens G (2018) Effect of tight control management on Crohn’s disease (CALM): a multicentre, randomised, controlled phase 3 trial. Lancet 390:2779–2789. CrossRefPubMedGoogle Scholar
  44. 44.
    Kaltz B, Bokemeyer B, Hoffmann J, Porschen R, Rogler G, Schmiegel W (2007) Überwachungskoloskopie bei Colitis ulcerosa in Deutschland. Z Gastroenterol 45:325–331. CrossRefPubMedGoogle Scholar
  45. 45.
    van Rijn AF, Fockens P, Siersema PD, Oldenburg B (2009) Adherence to surveillance guidelines for dysplasia and colorectal carcinoma in ulcerative and Crohn’s colitis patients in the Netherlands. World J Gastroenterol 15:226–230CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Siu AL (2015) Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 163:622–634. CrossRefPubMedGoogle Scholar
  47. 47.
    Biedermann L, Fournier N, Misselwitz B, Frei P, Zeitz J, Manser CN, Pittet V, Juillerat P, von Känel R, Fried M, Vavricka SR, Rogler G, for the Swiss Inflammatory Bowel Disease Cohort Study Group (2015) High rates of smoking especially in female Crohn’s disease patients and low use of supportive measures to achieve smoking cessation--data from the Swiss IBD Cohort Study. J Crohns Colitis 9:819–829. CrossRefPubMedGoogle Scholar
  48. 48.
    Miller DR, Rogers WH, Kazis LE, Spiro A III, Ren XS, Haffer SC (2008) Patients’ self-report of diseases in the Medicare Health Outcomes Survey based on comparisons with linked survey and medical data from the Veterans Health Administration. J Ambul Care Manage 31:161–177. CrossRefPubMedGoogle Scholar
  49. 49.
    Gama H, Correia S, Lunet N (2009) Questionnaire design and the recall of pharmacological treatments: a systematic review. Pharmacoepidemiol Drug Saf 18:175–187. CrossRefPubMedGoogle Scholar
  50. 50.
    Kappelman MD, Palmer L, Boyle BM, Rubin DT (2010) Quality of care in inflammatory bowel disease: a review and discussion. Inflamm Bowel Dis 16:125–133. CrossRefPubMedGoogle Scholar
  51. 51.
    Rubin G, Hungin APS, Chinn D, Dwarakanath AD, Green L, Bates J (2002) Long-term aminosalicylate therapy is under-used in patients with ulcerative colitis: a cross-sectional survey. Aliment Pharmacol Ther 16:1889–1893CrossRefPubMedGoogle Scholar
  52. 52.
    Gearry RB, Ajlouni Y, Nandurkar S, Iser JH, Gibson PR (2007) 5-Aminosalicylic acid (mesalazine) use in Crohn’s disease: a survey of the opinions and practice of Australian gastroenterologists. Inflamm Bowel Dis 13:1009–1015. CrossRefPubMedGoogle Scholar
  53. 53.
    Reddy SI, Friedman S, Telford JJ, Strate L, Ookubo R, Banks PA (2005) Are patients with inflammatory bowel disease receiving optimal care? Am J Gastroenterol 100:1357–1361. CrossRefPubMedGoogle Scholar
  54. 54.
    Zhu Q, Cao Q, Si J-M (2008) Quality of care for patients with inflammatory bowel disease in East China. World J Gastroenterol 14:612–616CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Medizinische Klinik m. S. Gastroenterologie, Infektiologie und Rheumatologie, Campus Benjamin FranklinCharité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
  2. 2.Klink für AnästhesieSegeberger KlinikenBad SegebergGermany
  3. 3.Medizinische Klinik ISt. MarienkrankenhausLudwigshafenGermany
  4. 4.Klinik für Innere Medizin – Gastroenterologie, Diabetologie und HepatologieVivantes Klinikum NeuköllnBerlinGermany

Personalised recommendations