Study design and setting

This study adopted a qualitative design with a descriptive orientation using an abductive analytical approach. Data were analysed inductively using thematic analysis to identify emerging themes, and the findings were subsequently mapped onto the Consolidated Framework for Implementation Research (CFIR) to provide a structured interpretation.

Semi-structured interviews were conducted to explore cardiologists’ perspectives on the implementation of PGx testing in cardiovascular care. The study was designed to generate in-depth insights into perceived barriers, facilitators, and system-level dynamics influencing the adoption of PGx in clinical cardiology. Data collection and reporting adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological rigour, transparency, and credibility [29] (Table S1 in S1 File).

The study was situated within the UAE healthcare system, which has witnessed rapid transformation through health reforms aimed at improving clinical service quality, expanding infrastructure, and promoting innovation. The UAE operates a mandatory private health insurance system, supported by both government-funded and private-sector healthcare providers. This dual-system structure plays a crucial role in shaping clinical decision-making, reimbursement practices, and the integration of emerging technologies, such as PGx [30,31].

Study tool: Development and validation

A semi-structured interview guide was designed to elicit rich, experience-based narratives while allowing participants to introduce ideas, reflect on personal clinical experiences, and highlight contextual factors beyond the scripted questions (Table S2 in S1 File).

A comprehensive literature review informed the guide on PGx adoption in clinical practice, and several question areas were adapted from previous qualitative studies on genomic medicine and health system implementation [32–34] The guide underwent expert review by PGx researchers and implementation science professionals, both locally and internationally, to ensure conceptual clarity and contextual relevance.

Although the guide was not explicitly structured around all CFIR constructs, its content was broadly aligned with its domains. This alignment supported the later application of CFIR as an analytical framework during data analysis and mapping of emergent themes.

The guide was piloted with two clinicians to refine the question flow and ensure clarity. It was then used consistently across interviews while allowing for probing and adaptation depending on participants’ responses.

Sample size and sampling

A total of 15 cardiologists were recruited using a combined purposive, convenience, and snowball sampling strategy. Eligible participants were adult cardiologists practising in general cardiology, heart failure, or congenital heart disease across the UAE. Inclusion criteria focused on those who actively prescribed medications commonly associated with PGx testing (e.g., antiplatelets, anticoagulants, statins) and who were involved in clinical decision-making or treatment protocol development.

Recruitment began through two major hospital administrations in different Emirates, which shared study invitations with eligible cardiologists on behalf of the research team. Those who chose to participate often suggested colleagues who might offer useful perspectives, thereby expanding the sample through professional networks. Sampling combined purposive and convenience strategies to include cardiologists with prescribing roles and direct experience in PGx-related care. The team also aimed for diversity in career stage, from early-career specialists to senior consultants and department heads, and in workplace setting, with participants representing both public and private institutions across Abu Dhabi, Dubai, Sharjah, and the northern Emirates.

A total of 20 cardiologists were invited; 15 agreed to participate and completed the interviews, while five declined due to time constraints or unfamiliarity with PGx. Sample size was guided by data saturation, with interviews continuing until no new codes or themes were identified. Saturation was assessed through concurrent coding, iterative comparison of emerging themes, and regular team discussions. No new themes were identified in the final interviews, indicating that code saturation had been achieved [35].

Data collection

Data were collected between November 2024 and February 2025. All interviews were conducted virtually via Microsoft Teams, audio-recorded with the participant’s consent, and transcribed verbatim by two independent investigators to ensure accuracy and minimise transcription bias.

All interviews were conducted by a female PhD candidate in Public Health, with a background in clinical pharmacy and formal training in qualitative research. She had no prior relationship with any of the participants.

Participants were initially invited via personalised emails, which included an information sheet and consent form. Reminder messages were sent one day and one hour before the scheduled interview to confirm attendance. Additionally, participants were sent the interview guide at least 48 hours in advance to allow them to reflect on the key discussion areas and prepare any comments or questions. The decision to share the interview guide in advance was intended to support more considered and practice-based responses, allowing participants to reflect on their real-world clinical experiences. Given the specialised and emerging nature of PGx, this approach helped ensure that responses were structured, relevant, and grounded in actual practice rather than being purely spontaneous or speculative. The interviews ranged from 30 to 60 minutes, depending on participant engagement and availability.

Theoretical framework and data analysis

A thematic analysis explored cardiologists’ perspectives on integrating PGx into routine practice. Using an abductive approach, data-driven codes were developed inductively from interview transcripts and iteratively interpreted through established implementation frameworks.

The transcripts were initially processed using an AI-based tool to assist in identifying preliminary codes and themes. The tool was used solely for initial code suggestions; all outputs were critically reviewed, refined, and manually validated by the research team to ensure accuracy and relevance.

To enhance analytic rigour, a subset of transcripts was independently coded by two researchers. Coding discrepancies were discussed and resolved through consensus during regular team meetings. In line with qualitative research standards, formal statistical measures of intercoder reliability were not applied; instead, emphasis was placed on consistency, reflexive dialogue, and agreement in interpretation. An audit trail of coding and analytic decisions was maintained throughout the process.

Reflexivity was embedded throughout the analysis to enhance transparency and minimise interpretive bias. The researcher’s positionality was explicitly considered, and the multidisciplinary research team, bringing expertise in public health, pharmacogenomics, and implementation science, contributed diverse perspectives to data interpretation. Reflexive journaling documented methodological decisions, evolving interpretations, and underlying assumptions, while regular peer debriefings supported critical reflection and consistency in analysis.

To ensure the trustworthiness of the findings, multiple strategies were employed. Credibility was enhanced through member checking with a subset of participants and sustained engagement with the data. Dependability was supported through the audit trail and ongoing team discussions. Confirmability was ensured through transparent documentation of analytic decisions, and transferability was addressed by providing detailed descriptions of the study context, participants, and healthcare setting.

Although the thematic analysis was conducted independently of any predefined framework, the CFIR was later applied as a conceptual lens to guide interpretation. The mapping of inductively generated themes onto CFIR constructs was conducted iteratively and reviewed collaboratively by the research team to ensure conceptual alignment and validity. A detailed mapping of themes and subthemes to the CFIR domains is provided in Table S4 in S1 File.

CFIR offers a comprehensive model for examining multi-level factors influencing healthcare implementation and integrates constructs from more than 20 theoretical models. It was selected for its established utility in evaluating PGx adoption across diverse clinical settings. A recent scoping review of pharmacogenetic studies further supports CFIR’s relevance in identifying common barriers and facilitators to PGx integration, underscoring its suitability for contextualising the present findings within the broader implementation literature [28].

Ethical considerations

This study was conducted with full ethical approval from the UAEU Social Sciences Ethics Committee on 24/06/2024 (Application No: ERSC_2024_4782), as well as additional approval from the hospital’s ethics committee (Approval No: MF2058-2024-1138). Ensuring participants’ rights, privacy, and comfort was a top priority throughout the research process. Participants received a clear explanation of the study’s purpose and procedures, and informed digital consent was obtained. Participation was voluntary, with the option to withdraw at any time without consequences. All interviews were anonymised, and recordings were securely stored on a password-protected system accessible only to the research team. Transcripts were reviewed to remove any identifying information before analysis. The study adhered to the Declaration of Helsinki and followed best practices for qualitative research, ensuring respect, autonomy, and confidentiality throughout the process.

Demographic and professional characteristics of participants

A total of fifteen cardiologists participated in the study. The majority were male (n = 10) and aged 45 years or older (n = 10). Most participants were employed in government healthcare institutions (n = 9), while the remainder worked in the private sector (n = 6). Nine cardiologists had 15 or more years of clinical experience, while six had fewer than 15. In terms of specialisation, the sample included six interventional cardiologists and six non-invasive cardiologists. None of the participants had received formal education or training in PGx (Table S3 in S1 File).

Thematic analysis

Thematic analysis of interview data identified four overarching themes reflecting cardiologists’ perspectives on the implementation of PGx in cardiovascular care. These themes encompass both systemic and individual dimensions influencing PGx awareness, perceived utility, and readiness for adoption. Subthemes within each category provide finer-grained insight into educational, organisational, and ethical contexts that shape clinical engagement with PGx.

Themes were generated inductively through iterative coding and constant comparison. They capture a spectrum of viewpoints ranging from limited awareness and perceived irrelevance to cautious optimism about PGx’s future role in precision cardiology. While some themes are conceptually related, they are presented separately to reflect different levels of influence on PGx implementation, including individual, organisational, and system-level factors. A summary of themes, subthemes, and supporting participant quotations is presented in Table 1, and the conceptual relationships are illustrated in Fig 1. This structure ensures analytic transparency while preserving the diversity of participant experiences and interpretations.

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Table 1. Summary of themes, subthemes, and representative quotations.

https://doi.org/10.1371/journal.pone.0351218.t001

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Fig 1. Cardiologists’ perspectives on pharmacogenomics implementation.

Thematic map showing major themes and subthemes identified from interviews with cardiologists regarding pharmacogenomics implementation, including knowledge gaps, organizational barriers, workforce readiness, and future opportunities.

https://doi.org/10.1371/journal.pone.0351218.g001

Intervention characteristics

This domain captures attributes of the innovation that shape uptake (relative advantage, evidence strength/design quality, complexity, adaptability/compatibility, cost, and trialability) [38].

Relative advantage was widely recognised, with cardiologists noting PGx’s potential to reduce adverse drug reactions and optimise cardiovascular prescribing. However, this perceived benefit has not yet translated into routine clinical use. Participants attributed this gap primarily to the lack of locally relevant outcome data and limited integration into clinical practice, which appeared to weaken confidence and delay adoption. Similar evidence–practice gaps have been reported in high-income settings, where validated gene–drug associations alone have been insufficient to drive implementation without context-specific data [39]

The strength and quality of the evidence also shaped perceptions. PGx was often viewed as originating in high-resource, external settings and as insufficiently tailored to local health system realities, thereby weakening its legitimacy and relevance [40]. Uncertainty around clinical ownership further contributed to implementation delays, reinforcing evidence that unclear roles can hinder adoption of complex interventions [41].

Complexity was a key barrier, particularly in acute cardiology settings requiring rapid decision-making. PGx was seen as burdensome in time-sensitive contexts, largely due to long turnaround times and limited integration into clinical systems. This reflects similar challenges reported in settings lacking real-time informatics support [42]. While participants recognised the value of integrating PGx with EHRs and clinical decision support (CDS), many considered the UAE’s current digital infrastructure underdeveloped for this purpose. Although national platforms such as NABIDH and MALAFFI have advanced digital health capacity, participants noted that these systems do not yet include PGx alerts or CDS, limiting their utility in real-world prescribing [43–45].

Adaptability was discussed in relation to care settings. Several cardiologists suggested that PGx would be more viable in non-acute environments, such as heart failure clinics or outpatient preventive cardiology, where continuity of care allows time for interpretation and patient engagement. This perspective mirrors NHS pilot experiences and highlights a UAE-specific opportunity for phased implementation in specialist settings [46].

Compatibility with existing workflows was viewed as limited. While PGx aligned conceptually with precision medicine, its fit within UAE cardiology was constrained by the pace of acute care, lack of integrated reporting, and reimbursement gaps. Similar barriers have been reported internationally, where poor Electronic Health Record (EHR) integration and complex report formats hinder real-time use [47,48]. In the Middle East, automation challenges in delivering PGx results through EHR systems have further reduced operational compatibility [49].

Cost emerged as a major perceived barrier, extending beyond the test price to include longer consultations, multidisciplinary coordination, and insurer reluctance to reimburse. Without demonstrable reductions in hospitalisations, adverse events, or prescribing inefficiencies, PGx was considered financially unattractive to both clinicians and payers. This uncertainty mirrors global trends, in which even well-validated tools stall without strong economic modelling and sustainable reimbursement frameworks [27,28]. Experiences from the UK and Canada illustrate this challenge: PGx initiatives were delayed or suspended despite strong clinical evidence due to low clinician awareness, fragmented funding, and the absence of sustainable financing models [39]. Some cardiologists drew parallels with telemedicine in the UAE, which initially struggled without alignment with reimbursement [50].

Trialability, the opportunity to pilot PGx before full-scale adoption, was viewed positively by several participants, who suggested small-scale rollouts in selected cardiology clinics to build local evidence, assess workflow impact, and refine integration strategies before broader implementation.

Outer setting

The CFIR domain of Outer Setting encompasses external factors that influence implementation, including patient needs and resources, external policies and incentives, peer pressure, external partnerships and global engagement [36].

Patient needs and resources emerged as a central influence on perceived PGx readiness. Several participants noted growing interest among younger, digitally engaged patients, who occasionally inquired about genetic factors affecting medication response. However, this interest was not matched by sufficient genomic literacy or awareness of PGx applications, limiting its translation into clinical demand [51–54]. Recent UAE evidence echoes these findings, showing that patients value medication safety and are generally open to proactive PGx testing; however, limited genomic literacy, concerns about cost, and privacy apprehensions remain key barriers to generating sustained clinical demand [55]. This suggests that patient interest alone is insufficient to drive implementation without parallel efforts to improve genomic literacy and access.

External policies and incentives were viewed as crucial for the adoption of PGx. Cardiologists agreed that national endorsement, insurance coverage, and formal support from the Ministry of Health were essential for integration [56]. International examples reinforced this: NHS England’s Genomic Medicine Service and Genome Canada’s national strategies both enabled PGx uptake through funding and policy alignment [57,58].

Engagement with external peers and global benchmarking also shaped attitudes. Many participants cited PGx integration in the U.S., UK, and Canada as hallmarks of modernised healthcare, perceiving adoption in the UAE as an opportunity to enhance institutional reputation and future readiness [59,60]. However, this aspirational view was often tempered by recognition that the UAE is at an earlier stage of implementation, with infrastructure and policy frameworks still evolving.

In the absence of clear national mandates, several cardiologists advocated for locally driven pilot programs as pragmatic entry points. Suggested approaches included public–private partnerships, shared-risk funding, and hospital-level initiatives to generate local outcome data, refine workflows, and build institutional momentum before large-scale adoption. This mirrors successful implementation efforts elsewhere, where pilot studies engaged stakeholders, secured buy-in, and informed scale-up strategies [61]. In the UAE context, locally led pilot initiatives could serve as a practical mechanism for bridging the current policy–practice gap.

Inner setting

The CFIR domain of Inner Setting refers to the structural, cultural, and operational features within organisations that influence implementation, including structural characteristics, leadership engagement, communication networks, and resource availability [36].

Structural characteristics and infrastructure varied widely between institutions. Cardiology services in the UAE are characterised by differences in infrastructure, decision-making culture, and access to genomic technologies across public and private sectors [31]. Clinicians in tertiary hospitals reported better access to diagnostics, supportive leadership, and electronic systems that support PGx integration, whereas those in smaller or mixed-practice settings described limited capacity and resources. This aligns with global evidence that implementation readiness often depends on facility size, infrastructure, and internal capabilities [58,62].

Networks and communication also influenced readiness. While cardiologists acknowledged the importance of interdisciplinary input, particularly from pharmacists and laboratory professionals, they noted the absence of formal structures to support shared decision-making. This mirrors broader patterns where fragmented communication has hindered PGx uptake and underutilised pharmacist expertise [42].

Leadership engagement emerged as a potential enabler, especially in institutions where department heads encouraged education and exploration. However, this support was often informal and verbal rather than embedded in strategic plans, guidelines, or policy. Such passive endorsement, without formalisation, is a common barrier in implementation, often resulting in stalled or fragmented adoption [63].

Available resources were identified as one of the most immediate barriers. Cardiologists cited the absence of on-site PGx testing facilities, reliance on external laboratories with long turnaround times, and a shortage of trained personnel to support test interpretation and clinical integration. These constraints slowed decision-making and discouraged uptake in fast-paced cardiology settings. Similar challenges are documented in genomic medicine literature, particularly in systems undergoing digital transition or operating in hybrid public–private models [64,65].

In addition, the absence of integrated decision-support tools and genomic informatics capacity may further undermine clinician confidence, as reliance on fragmented information and self-interpretation has been shown to impede safe PGx use [66].

The lack of institutional investment in PGx-specific infrastructure was interpreted not only as a logistical limitation but also as a signal that PGx was not yet prioritised within organisational missions. This reflects findings from global studies where insufficient institutional alignment and resourcing slowed the integration of precision medicine into routine care [67,68].

Characteristics of individuals

The CFIR domain of Characteristics of Individuals addresses how personal attributes such as knowledge, attitudes, confidence, and readiness for change influence clinicians’ engagement with a new intervention [28]. Cardiologists expressed general support for PGx, particularly its potential to improve drug safety, but this was not matched by practical readiness

Many participants reported low confidence in ordering tests, interpreting results, and integrating findings into treatment decisions, especially under time constraints.This highlights a gap between positive attitudes and self-efficacy, a pattern also observed in other healthcare settings [34].

Limited exposure to formal PGx education further compounded low confidence. Most cardiologists were unfamiliar with internationally endorsed implementation resources [11,69]. None of the participants recalled PGx-focused lectures, workshops, or CME events during training or practice. In the absence of structured educational programs or institutional protocols, learning was inconsistent, self-directed, and often reliant on informal reading or rare clinical cases. This mirrors findings from other regions, where low familiarity with PGx resources has been identified as a core barrier to adoption [70,71], reinforcing the need for targeted professional development and integration of PGx into cardiology-specific training pathways [72].

Several cardiologists perceived PGx as burdensome rather than facilitative. In fast-paced environments, unclear responsibilities, logistical complexity, and lack of decision-support tools were cited as deterrents. These perceptions suggest that when PGx is seen as adding workload or disrupting workflow, adoption is unlikely despite favourable attitudes, consistent with broader implementation literature [12,73].

Implementation process

The CFIR domain of Implementation Process captures the planning, engagement, execution, and evaluation activities that drive an innovation from concept to routine use [38]. In this study, cardiologists identified multiple gaps in process design, stakeholder coordination, and institutional follow-through, reflecting a healthcare environment where PGx is supported in theory but remains underdeveloped in practice.

National PGx guidelines exist in the UAE, yet participants reported low awareness and limited uptake in cardiology. They noted that existing guidance was often shared through generic circulars lacking adaptation to cardiovascular workflows or time-pressured decision-making. This reflects global concerns that national strategies without frontline tailoring rarely achieve effective implementation [74].

Stakeholder coordination was described as minimal, with disjointed communication between laboratories, insurers, and allied health professionals and no formal multidisciplinary workflows. International examples, including the IGNITE Network and NHS Genomic Medicine Service, highlight that structured engagement through task forces and advisory committees can be critical for system-wide PGx adoption [74–76]

Only one participant reported involvement in a PGx-related study, and others noted no local pilot projects to establish feasibility. Globally, pilot initiatives have been shown to demonstrate operational viability, generate context-specific outcome data, and secure institutional and payer support [74].

Participants also reported no evaluation mechanisms, including systems to monitor test use, prescribing changes, or patient outcomes. Without such feedback systems, sustained implementation is unlikely, as monitoring and evaluation are critical components of successful integration [73].

Beyond its practical implications, this study contributes to implementation science by applying the CFIR within a hybrid public–private healthcare system and a cardiology-specific context. The findings highlight how implementation factors interact across multiple levels, particularly in settings characterised by fragmented workflows, variable resources, and evolving policy environments. This reinforces the value of CFIR as a flexible framework for understanding context-dependent implementation challenges and extends its application to pharmacogenomics in cardiology within hybrid health systems.

Building on these findings, a stepwise implementation framework is proposed to support the integration of PGx across services. The framework comprises twelve linked steps: evidence synthesis; tailored communication of guidance; short case-based training; clear eligibility criteria; a one-page ordering/approval workflow; a time-limited pilot in one to two centres; EHR integration (structured results with point-of-care support); reimbursement and coding alignment; role clarity (including a PGx-trained pharmacist or genetics clinician); laboratory capacity with timely turnaround and standardised reporting; governance, consent, and privacy; and dashboard-led evaluation with phased scale-up (Fig 3).

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Fig 3. Proposed implementation framework for pharmacogenomics in hybrid health systems.

Stepwise framework outlining key actions for pharmacogenomics implementation, including evidence generation, guideline localization, workforce training, workflow integration, reimbursement alignment, governance, and evaluation.

https://doi.org/10.1371/journal.pone.0351218.g003

Strengths and limitations

This study provides early, practice-grounded insights into the implementation of PGx in a hybrid health system, drawing on accounts from practising cardiologists across public and private hospitals. The use of the CFIR enabled a structured, multilevel analysis and facilitated comparison with international literature.

Some limitations should be considered. First, the study focused only on cardiologists and did not include other key stakeholders such as patients, pharmacists, payers, or laboratory professionals, which may limit the breadth of perspectives captured. Second, the use of purposive, convenience, and snowball sampling may introduce selection bias, as participants may have been more familiar with or positively inclined toward PGx, potentially influencing the views reported and limiting generalisability. Third, as the study was conducted in a single country, the findings may not be fully transferable to other healthcare systems.

In addition, most participants had limited formal education or hands-on experience in PGx, which may have shaped their perceptions and affected the transferability of findings to settings with more established PGx implementation. Although online interviews enabled participation across multiple regions, this format may have limited the ability to capture nonverbal cues and influenced rapport during data collection. Future research should adopt multi-stakeholder and mixed-method approaches to triangulate findings and support more scalable implementation strategies.