Frameworks for adaptation of health guidelines: a systematic survey update

Guideline development is both time-consuming and resource-intensive, and duplication of efforts contributes to research waste. Although adopting existing guidelines is an efficient alternative, it often fails to account for contextual factors. Adapting trustworthy, previously developed relevant guidelines offers a promising alternative. Thus, we aimed to identify, describe, and evaluate formal frameworks for the adaptation of health-related guidelines.

We updated a previously published systematic survey of guideline adaptation frameworks by searching MEDLINE (Ovid) and Embase (Ovid) from January 1, 2015, to October 31, 2025. Eligible studies described an adaptation framework for health guidelines in sufficient detail to allow reproducibility. We excluded reviews, guideline adaptations, and implementation reports. We extracted in duplicate and independently data on framework characteristics and presented results in both narrative and tabular formats.

Our search identified 20 guideline adaptation frameworks, up from eight identified in the previous survey. These frameworks included five to 24 steps (median: 13). Each framework followed 1 of four primary approaches: ADAPTE-based (6/20); GRADE-ADOLOPMENT-based (3/20); hybrid approaches (2/20); and other approaches (9/20). ADAPTE-based frameworks follow a comprehensive three-phase, 24-step process to assess and modify entire source guidelines. In contrast, GRADE-ADOLOPMENT-based frameworks focus on recommendation-level contextualization using Evidence to Decision frameworks. The remaining frameworks utilized other methods for their jurisdiction or organization-specific contexts. The most frequently reported challenges were high resource and expertise requirements, dependence on the quality and availability of source guidelines, contextual and implementation barriers, and limited capacity for new evidence synthesis.

Guideline adaptation frameworks vary substantially in scope and methods, reflecting a balance between methodological rigor and feasibility. ADAPTE- and GRADE-ADOLOPMENT-based approaches provide structured methods, while more recent frameworks prioritize flexibility. This synthesis will help guideline developers select approaches that best fit their context and resources.

Why did we do this study? Health guidelines help doctors, patients, policymakers, and other relevant interest-holders make decisions that are informed by the best available evidence and the realities of their setting. Creating a new trustworthy guideline from scratch is time-consuming and requires substantial resources. An alternative is to adapt an existing high-quality guideline from another organization. This involves systematically modifying and contextualizing the recommendations to fit local needs, priorities, and resources. To do this effectively, teams rely on structured, step-by-step approaches known as adaptation frameworks, which provide practical guidance on how to carry out this process. We conducted a review of the literature to identify, describe, and evaluate all the different frameworks available for adapting guidelines. What did we do? We searched the medical literature for articles that described a framework for adapting health guidelines. This study is an update of a similar review we published in 2017. What did we find? We found 20 different frameworks, 12 more than were found in the 2017 review. Some (6 frameworks) are based on the ADAPTE approach and provide a detailed, step-by-step process to review and modify an entire guideline. Others (3 frameworks) are based on the GRADE-ADOLOPMENT approach and focus on assessing and adapting individual recommendations. Two frameworks combine elements of both ADAPTE and GRADE. The remaining frameworks (9) are practice-based approaches, often developed to meet the specific needs of a country, region, or clinical area. What are the common challenges? The adaptation process requires considerable time and expertise and depends on the quality and availability of an existing high-quality guideline. Additional challenges include contextual and implementation barriers, and limited capacity to search for and incorporate new evidence. What does this mean? This review provides a summary of 20 frameworks for adapting guidelines. Guideline developers can now compare the different options and choose the framework that best fits their needs.