What is the Classification of Pharmaco-Therapeutic Referrals?


The Classification of Pharmaco-Therapeutic Referrals (CPR) is a taxonomy focused on defining and grouping together situations requiring a referral from pharmacists to physicians (and vice versa) regarding the pharmacotherapy used by the patients. It has been published in 2008. It is bilingual: English/Spanish (Clasificación de Derivaciones Fármaco-terapéuticas).

It is a simple and efficient classification of pharmaco-therapeutic referrals between physicians and pharmacists permitting a common inter-professional language. It is adapted to any type of referrals among health professionals, and to increase its specificity it can be combined with ATC codes, ICD-10, and ICPC-2 PLUS.

It is a part of the MEDAFAR Project, whose objective is to improve, through different scientific activities, the coordination processes between physicians and pharmacists working in primary health care.

Supporting Institutions

  • Pharmaceutical Care Foundation of Spain (Fundación Pharmaceutical Care España).
  • Spanish Society of Primary Care Doctors (Sociedad Española de Médicos de Atención Primaria) (SEMERGEN).


  • Raimundo Pastor Sánchez (Family practice, “Miguel de Cervantes” Primary Health Centre SERMAS Alcalá de Henares – Madrid – Spain).
  • Carmen Alberola Gómez-Escolar (Pharmacist, Vice-President Fundación Pharmaceutical Care España).
  • Flor Álvarez de Toledo Saavedra (Community pharmacist, Past-President Fundación Pharmaceutical Care España).
  • Nuria Fernández de Cano Martín (Family practice, “Daroca” Primary Health Centre SERMAS Madrid – Spain).
  • Nancy Solá Uthurry (Doctor in Pharmacy, Fundación Pharmaceutical Care España).


It is structured in 4 chapters (E, I, N, S) and 38 rubrics. The terminology used follows the rules of ICPC-2.

Each rubric consists in an alphanumeric code (the letter corresponds to the chapters and the number to the component) and each title of the rubric (the assigned name) is expressed and explained by:

  • A series of terms related with the title of the rubric.
  • A definition expressing the meaning of the rubric.
  • A list of inclusion criteria and another list with exclusion criteria to select and qualify the contents corresponding to a rubric.
  • Some example to illustrate every term.

It also includes a glossary of 51 terms defined by consensus, an alphabetical index with 350 words used in the rubrics; and a standardised model of inter-professional referral form, to facilitate referrals from community pharmacists to primary care physicians.

Classification of Pharmaco-Therapeutic Referrals MEDAFAR

E. Effectiveness/Efficiency

  • E 0. Effectiveness / Efficiency, unspecified.
  • E 1. Indication.
  • E 2. Prescription and dispensing conditions.
  • E 3. Active substance / excipient.
  • E 4. Pharmaceutical form / how supplied.
  • E 5. Dosage.
  • E 6. Quality.
  • E 7. Storage.
  • E 8. Consumption.
  • E 9. Outcome.

I. Information/Health Education

  • I 0. Information / health education, unspecified.
  • I 1. Situation / reason for encounter.
  • I 2. Health problem.
  • I 3. Complementary examination.
  • I 4. Risk.
  • I 5. Pharmacological treatment.
  • I 6. No pharmacological treatment.
  • I 7. Treatment goal.
  • I 8. Socio-healthcare system.

N. Need

  • N 0. Need, unspecified.
  • N 1. Treatment based on symptoms and/or signs.
  • N 2. Treatment based on socio-economic-work issues.
  • N 3. Treatment based on public health issues.
  • N 4. Prevention.
  • N 5. Healthcare provision.
  • N 6. Complementary test for treatment control.
  • N 7. Administrative activity.
  • N 8. On patient request (fears, doubts, wants).

S. Safety

  • S 0. Safety, unspecified.
  • S 1. Toxicity.
  • S 2. Interaction.
  • S 3. Allergy.
  • S 4. Addiction (dependence).
  • S 5. Other side effects.
  • S 6. Contraindication.
  • S 7. Medicalisation.
  • S 8. Non-regulate substance.
  • S 9. Data / confidentiality.

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Mental Health Providers & Burnout

Research Paper Title

Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study.


In the Veterans Health Administration (VHA), mental health providers (MHPs) report the second highest level of burnout after primary care physicians. Burnout is defined as increased emotional exhaustion and depersonalisation and decreased sense of personal accomplishment at work.

Therefore the aim of this study is to characterise variation in MHP burnout by VHA facility over time, identifying workplace characteristics and practices of high-performing facilities.


Using both qualitative and quantitative methods, the researchers will evaluate factors that influence MHP burnout and their effects on patient outcomes. They will:

  • Compile annual survey data on workplace conditions and annual staffing as well as productivity data to assess same and subsequent year provider and patient outcomes reflecting provider and patient experiences.
  • Conduct interviews with mental health leadership at the facility level and with frontline MHPs sampled based on our quantitative findings.
  • Present their findings to an expert panel of operational partners, Veterans Affairs clinicians, administrators, policy leaders, and experts in burnout.
  • Reengage with facilities that participated in the earlier qualitative interviews and will hold focus groups that share results based on our quantitative and qualitative work combined with input from our expert panel.
  • Broadly disseminate these findings to support the development of actionable policies and approaches to addressing MHP burnout.


This study will assist in developing and testing interventions to improve MHP burnout and employee engagement. Their work will contribute to improvements within VHA and will generate insights for health care delivery, informing efforts to address burnout.


This is the first comprehensive, longitudinal, national, mixed methods study that incorporates different types of MHPs. It will engage MHP leadership and frontline providers in understanding facilitators and barriers to effectively address burnout.


Zivin, K., Kononowech, J., Boden, M., Abraham, K., Harrod, M., Sripada, R.K., Kales, H.C., Garcia, H.A. & Pfeiffer, P. (2020) Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study. JMIR Research Protocols. 9(12), pp.e18345. doi: 10.2196/18345.

Primary Care Physicians & the Mental Health Gap Action Programme (mhGAP)

Research Paper Title

Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial.


To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area.

Non-specialists (such as PCPs)’ training is an internationally supported way to target untreated mental health symptoms.


The researchers aimed to evaluate the programme’s impact on PCPs’ mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training.

They conducted an exploratory trial with a combination of designs: a pretest-posttest control group design and a one-group pretest-posttest design were used to assess the training’s short-term impact; and a repeated measures design was used to assess the training’s long-term impact.

The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1).

The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers.

Data were collected at baseline, following Group 1’s training, following Group 2’s training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted.

Overall, 112 PCPs were randomised to either Group 1 (n = 52) or Group 2 (n = 60).


The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice.

When comparing pre-training results and results 18 months after training, these changes were maintained.

PCPs reported a decrease in referral rates to specialised services 18 months after training in comparison to pre-training.


The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries.

Future studies should examine relationships among these outcome variables.


Spagnolo, J., Champagne, F., Leduc, N., Rivard, M., Melki, W., Piat, M., Laporta, M., Guesmi, I., Bram, N. & Charfi, F. (2019) Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial. Health Policy and Planning. pii: czz138. doi: 10.1093/heapol/czz138. [Epub ahead of print].