Scope of Practice Variation Across the United States: Barriers to Standardization, Differences, and Policies That Affect Registered Radiologist Assistants (RRAs) Utilization By Angela Smith Avery Behrle Becca Mace Deq Sufi Gabriela Sanchez Relova Heather Daffin Jenna Rodriguez Jessica Gussler Jolanta Pas Katie Foster Ken Rausch Kristen Cheney Nick Diliberto Rachel Curry Raul Marquez Shamala Purohit Sydney Gilmore A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah August 2, 2026 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Angela Smith Avery Behrle Becca Mace Deq Sufi Gabriela Sanchez Relova Heather Daffin Jenna Rodriguez Jessica Gussler Jolanta Pas Katie Foster Ken Rausch Kristen Cheney Nick Diliberto Rachel Curry Raul Marquez Shamala Purohit Sydney Gilmore This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Taylor Ward, PhD MSRS Faculty ______________________________ Dr. Laurie Coburn, EdD MSRS Radiologist Assistant Program Director ______________________________ Dr. Tanya Nolan, EdD MSRS Medical Imaging Leadership Program Director THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by MSRS Students This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 ____________________________________ Angela Smith ____________________________________ Avery Behrle ____________________________________ Becca Mace ____________________________________ Deq Sufi ____________________________________ Gabriela Sanchez Relova ____________________________________ Heather Daffin ____________________________________ Jenna Rodriguez ____________________________________ Jessica Gussler August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 August 2, 2026 ____________________________________ Jolanta Pas ____________________________________ Katie Foster ____________________________________ Ken Rausch ____________________________________ Kristen Cheney ____________________________________ Nick Diliberto ____________________________________ Rachel Curry ____________________________________ Raul Marquez ____________________________________ Shamala Purohit ____________________________________ Sydney Gilmore SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 5 Introduction and Background The role of the registered radiologist assistant (RRA) has evolved to address the increasing demand for imaging services, ongoing radiologist shortages, and the growing complexity of medical imaging technologies. An RRA is an advanced-level radiographer credentialed through the American Registry of Radiologic Technologists (ARRT), functioning under the direct supervision of a radiologist to enhance workflow efficiency, improve patient care, and support both diagnostic and interventional imaging procedures. These highly trained professionals complete an advanced academic program and a radiologist-directed clinical preceptorship, positioning them as integral members of the radiology team. Despite the profession’s clear value in improving access and continuity of imaging care, the scope of practice (SOP) for RRAs remains highly variable across the United States. National organizations such as the ARRT provide certification standards, and the American Society of Radiologic Technologists (ASRT) outlines a standardized curriculum for RRA education. However, the implementation and legal recognition differ widely between states, driven by variations in laws, regulatory frameworks, and institutional policies. These differences determine what procedures RRAs may perform, how supervision is defined, and whether reimbursement is permitted. The ARRT and ASRT distinguish between several levels of supervision: direct, general, indirect, and personal. Direct supervision occurs when the radiologist is physically present and immediately available; general supervision indicates the radiologist is not present but available for consultation; indirect supervision typically implies even less involvement; and personal supervision requires the radiologist’s active, in-person participation during the procedure. These distinctions illustrate the variability of oversight and autonomy across institutions. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 6 Lack of national standardization entails inconsistent credentialing requirements among different medical practices, differing interpretations of supervision levels by state medical boards, limited third-party reimbursement, and institutional hesitancy to expand procedural privileges. Although professional bodies such as the American College of Radiology (ACR) and ASRT provide guidance on RRA practice, their recommendations depend heavily on local governance. Consequently, RRA utilization varies significantly across the US, leading to disparities in patient access, professional recognition, and career sustainability. As the healthcare system shifts toward value-based care and team-based delivery models, the case for a standardized, nationally recognized RRA profession grows stronger. A consistent scope of practice would ensure equitable patient access, workforce stability, and reinforce the RRA’s role as a crucial partner in high-quality, patient-centered radiology care. This research examines RRA's scope of practice variation across U.S. regions, identifies areas lacking in standardization, and analyzes how policy frameworks and legislative differences affect RRA utilization. Research was conducted by Weber State University graduate students residing throughout the United States. Peer-reviewed literature will identify barriers within the RRA profession. States were organized into regions—the Northeast, Midwest, South, and West—to assess regional patterns and policy trends. Statement of the Problem Despite standardization criteria provided by the ARRT and the ASRT, the precise role of the RRA is nonuniform nationwide due to differences in scope of practice laws, supervision definitions, and reimbursement policies, which prevents their consistent utilization. The first problem identified is the state-level scope of practice. The skills utilized by RRAs vary by state law, creating inconsistencies in operations across the country despite uniform ARRT SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 7 credentialing. The ARRT requires competence in gastrointestinal, genitourinary, chest, invasive nonvascular, and invasive vascular procedures (ARRT, 2024). However, as previously stated, inconsistencies at the state, local and institutional level can further restrict the procedures allowed to be performed by an RRA. Another issue is the definitions of supervision. The ARRT and ASRT define multiple supervision levels: direct, general, indirect, and personal. However, state laws and institutional policies create significant variation in how these are applied. For example, some states grant RRAs a defined legal scope through licensing boards or medical practice acts, while others lack specific statutory recognition of their role (Society of Radiology Physician Extenders, 2024). These discrepancies in licensure and scope of practice laws limit workforce mobility and affect the efficiency of radiology teams, as individual state practice acts determine both the clinical functions and supervisory requirements for RRAs (California Assembly Bill 3097, 2024). Lastly, policy efforts to standardize and expand RRA utilization has focused primarily on state-level legislative advocacy and federal reimbursement reform. The ASRT and ACR jointly advocate for inclusion of RRAs in the Medicare Physician Fee Schedule to allow billing for radiologist-supervised services. Legislative initiatives, such as the RA Medicare Access to Radiology Care Act (MARCA)—introduced multiple times in Congress—seek to establish national reimbursement recognition. Although these efforts have gained bipartisan support, they have yet to be enacted (ASRT, 2023). Significance of the Problem Addressing these issues will result in several benefits. Standardizing RRA scope of practice would improve education, clarify institutional policy, and allow radiologists to utilize SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 8 RRAs fully. As it currently stands, the role of the RRA is a bit foreign to most healthcare professionals, leading to underutilization and confusion regarding the RRA scope of practice. According to the ARRT credential statistics census, approximately 488 radiologist assistants are registered with the ARRT and hold an active RRA credential (American Registry of Radiologic Technologists, 2025). Ultimately, the healthcare facility or radiology group that employs the RRA will utilize them as they see fit to meet their needs, within nationally accepted standards or evidence-based practices. With a standardized role of expectations, radiologists should be able to better utilize the RRA and continue to grow and further develop their professional skills through targeted skill development and increased responsibility. For instance, adding more continuing education resources for the RRA as well as appreciating that they are, in fact, mid-level providers who can be a great point of contact for physicians with radiologyspecific questions and/or concerns, will help increase the value behind the RRA name. This recognition would lead to a stronger advocacy for policy changes that reflect the RRA contributions, including legislative regulated guidelines, and medical reimbursements for health insurance companies that have yet to recognize the contributions RRAs provide to a medical facility. Purpose of the Study The goal of this quasi-experimental and mixed-methods study is to analyze how RRAs are utilized across the country. The ARRT has established guidelines for what procedures an RRA can perform. However, different states have the ability to set boundaries within the scope of practice and hospitals, and private groups can further restrict what procedures are allowed. Further clarification is warranted that this study will neither establish or eliminate any standards SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 9 or regulations that govern RRAs currently. This study is intended to help bridge the educational gap between the utilization of RRAs and the broader network of healthcare providers. Weber State University students in the Master of Radiologic Sciences program sent out surveys to RRAs across the country to gather information about their employment status, location, and procedures performed. This information will ideally clarify regional discrepancies and guide future efforts towards uniform scope of practice. Research Questions ● How does the scope of practice for RRAs vary across different states and regions in the United States? ● Does the scope of practice differ based on years of experience? ● How does the level of supervision affect scope of practice? ● Is there a significant difference between job satisfaction and practice setting? ● Is there a significant difference between job satisfaction and salary range? ● Is there a significant difference between job satisfaction and scope of practice? ● Is there a significant difference between job satisfaction and region? Limitations Surveys are a practical way to collect large amounts of quantitative information; however, they have several limitations that can impact the interpretation of the results. According to Ross and Zaidi (2019), people generally change their behavior when they know their responses are being evaluated, a phenomenon known as the Hawthorne effect. People tend to choose responses that sound more professional or socially acceptable. This habit, referred to as social desirability bias (Krumpal, 2013), can cause results to appear more positive than they are. In this context, RRAs might exaggerate their autonomy, job satisfaction, or institutional support SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 10 to meet perceived professional expectations or to create a positive image of their workplace. In contrast, some RRAs may underreport their level of support because they are frustrated by their institutions' uneven use of their skills, inadequate recognition, or role limits. These contradictory tendencies highlight the subjectivity of self-reported data and the challenges in extrapolating findings without external verification. Sampling bias is another issue. When the surveyed group does not reflect the broader RRA population, results may lean toward specific experiences or viewpoints. Since this survey will primarily be disseminated through academic and professional networks, it is likely to reach active RRAs working in larger health systems. Those in smaller hospitals or in states where the RRA roles that are not formally recognized were missed. Past research using convenience samples has consistently shown a similar pattern: highly engaged professionals are often the ones who respond, while those with fewer institutional ties are typically excluded (Rüdig, 2010). Online distribution presents an additional difficulty because participation may be lower among older professionals or those with less internet access. Designing, sharing, and analyzing surveys also require considerable time and effort, which can limit the amount of data that can be collected. Differences in professional standards present another layer of limitation. The ARRT and the ASRT both outline a national scope of practice for RRAs; however, these standards are often subject to change under state laws or local policies. As a result, some participants may base their answers on their workplace’s expectations rather than on national definitions. The limited number of published studies about the RRA profession also makes comparison difficult. Furthermore, variations in legislation, credentialing, and reimbursement among states limit the broad applicability of these results. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 11 Delimitations This study is delimited to RRAs who are currently licensed and practicing within the United States. The purpose of this research is to examine how the regulations established by the ARRT, ASRT, insurance reimbursement practices, and hospital preferences align in relation to the RRA role. RRAs practicing outside of the United States are excluded from this study, as are other advanced practice providers who work alongside RRAs, such as radiologists. Data collection occurred through a survey that was conducted from Wednesday, April 22, 2026, and closed on Wednesday, June 3, 2026 . The study was confined to the current experiences and perspectives of actively practicing RRAs to ensure the findings accurately reflect the context of the U.S. healthcare system. Summary The demand for RRAs has increased due to a shortage of radiologists and the growing workload within the imaging field, prompting practices to integrate advanced practitioners to help manage service volume and maintain patient access (American College of Radiology Bulletin, 2024). Registered Radiologist Assistants are ARRT-certified advanced radiologic technologists who work under the supervision of radiologists and perform clinical tasks to extend radiologic services (American Registry of Radiologic Technologists, 2025). RRAs play a critical role in performing advanced imaging procedures and enhancing patient care by assisting with patient assessment, management, and select clinical imaging tasks under radiologist supervision (American Society of Radiologic Technologists, 2019; ARRT, 2023). However, despite standardized advanced training and national board certification, significant discrepancies exist in the scope of practice and reimbursement across regions in the SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 12 United States, including variations in permissible procedures, supervision requirements, and Medicare reimbursement policies (ARRT Government Affairs, 2025; ASRT state practice standards; SRPE legislative discussions), which contribute to workforce challenges and inconsistent understanding of the RRA role among health care professionals. Looking at how RRA supervision is interpreted differently by state government and healthcare institutions, the resulting inconsistencies may cause delays in workforce efficiency. This may discourage healthcare professionals from entering the field or remaining in the profession. Through this study, by implementing quasi-experimental and mix-method designs, the graduate RRA students aimed to gain insight into identifying the discrepancies and understand RRA utilization across the country. In addition, the study examined the regional differences, legal issues and how closely the RRAs are practicing compared to the ARRT guidelines, suggesting a more common definition of the role of RRAs nationwide. II. REVIEW OF LITERATURE Introduction This literature review examines the scope of practice variations among RRAs across the United States, identifying barriers, policy differences, and systemic factors that influence the standardization and utilization of this professional role. Reviewing existing literature clarifies how an RRA is defined, regulated, and employed across different regions and highlights policy and practice gaps that contribute to regional discrepancies. These variations have direct implications on the workforce, efficiency, patient access, and healthcare quality. The radiology community is facing a shortage of radiologists coupled with an increase in the volume of imaging and image-guided procedures. The growing demand for healthcare SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 13 services has led to the creation of the advanced-level radiologic technologist known as an RRA, in 2002. This position was created to improve workflow and ensure service continuation by assigning specific radiology tasks to advanced-level technologists (ASRT, 2002). By allowing qualified experts to handle designated imaging and procedural activities, radiologists can dedicate more time to complex interpretation and diagnostic responsibilities. Clear and consistent rules defining the RRA’s legal scope of practice are essential to safe, effective care. Understanding national variation can inform advocacy to expand the appropriate scope and support effective, uniform utilization of RRAs. Variability in the Scope of Practice and Supervision of R.R.A.’s Historically, the RRA's role emerged from collaboration between the ACR and the ASRT to address radiologist shortages and improve patient care efficiency (Williams & Short, 2004; Ellenbogen et al., 2007). The concept was designed to allow advanced radiographers to perform certain delegated procedures under radiologist supervision, enhancing workflow and supporting diagnostic and interventional services. Early evidence demonstrated that incorporating an RRA improved productivity, reduced radiologist workload, and maintained a higher standard of patient care (Ellenbogen et al.,2007). According to Poss and Wassenaar (2007), the evolution and role of RRAs in the United States are remarkable. RRAs have advanced from filling the void of increased imaging demands and radiologist shortages to high-level imaging tasks and patient evaluations. Technological advancements have also significantly contributed to the creation of this role. ARRT establishes national credential expectations for RRAs. Each RRA completes an accredited graduate program, mandatory clinical training, and demonstrates proficiency in gastrointestinal, genitourinary, chest, invasive nonvascular, and invasive vascular procedures SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 14 (ARRT, 2023). Despite this standardized training, the degree to which these skills are utilized varies widely across states. Predictions from The Harvey L. Neiman Health Policy Institute (2025) indicates that by 2055, imaging utilization in the U.S. is expected to increase by 16.9%-26.9% (compared to 2023), while the increase in radiologist supply is expected to be approximately 25.7%. Recent workforce analyses, such as national radiologist labor force projections and imaging utilization models published by Rawson et al. (2024) and the Harvey L. Neiman Health Policy Institute (2025), demonstrate that the radiology workforce is under substantial strain due to a widening gap between imaging demand and radiologist supply. State Legislation and Supervision Differences Scope of practice laws vary considerably between states. For example, Texas Occupations Code § 601.1021 (2023) permits radiologist assistants to perform radiologic procedures under supervision but restricts interpretation, diagnosis, and prescribing authority. Conversely, Minnesota Administrative Rules r. 4732.0306 limits fluoroscopy use when a supervising radiologist is not physically present and lacks clear regulations for RRA /RPAs. However, Utah provides a distinct example, allowing indirect or general supervision in critical access hospitals where a Delegation of Services Agreement defines the procedures the RRA may perform (Radiologic Technologist, Radiologist Assistant, and Radiology Practical Technician Licensing Act, 2011). Despite such regional flexibility, all states maintain restrictions on interpretation, diagnosis, and prescribing authority, which limit the RRA’s autonomous function. Supervision Requirements and Regulatory Disparities The ASRT Radiologist Assistant Practice Standards (2019), outline national expectations for clinical responsibility, patient safety, and procedural quality under radiologist supervision. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 15 Yet, despite these professional standards, the level of enforcement and recognition varies widely across states (State Statutes and Regulations for Radiologist Assistant: Supervision, Delegation, and Scope of Practice, 2025). State differences in regulations, along with Medicare and Medicaid rules, make it difficult for RRAs to practice consistently. According to Koveleskie and Wood (2011), the Centers for Medicare and Medicaid Services (CMS) has been reluctant to recognize RRAs as independent providers because of concerns that the scope of practice is beyond their training and considered more than state statutes would withstand. In comparison, Physician Assistants (PAs) can bill independently and be reimbursed for their services. Reimbursement Federal reimbursement policy adds to these inconsistencies. CMS requires that imaging services be billed under appropriate supervision levels for reimbursement eligibility (Greeson & Pitts, 2011). Because Medicare does not recognize RRAs as independent providers, their services must occur under direct supervision (Hawkins et al., 2015). This restriction reduces financial incentives for institutions to employ RRAs and limits flexibility in staffing, particularly in rural settings (Hart et al., 2021; Barten et al., 2019). Advocacy Initiatives Advocacy initiatives continue to address these barriers through the Medicare Access to Radiology Care Act (MARCA). These efforts aim to align reimbursement policies with state licensure laws (Taft & Fischer, 2025). The bill was last introduced to the U.S. Senate in December 2024 but did not advance (Current Government Affairs Projects, n.d.). The ACR, a founding partner in the RRA initiative, initially supported the profession but later adopted a neutral stance on MARCA due to supervision and revenue concerns. Conversely, organizations SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 16 such as the Society of Interventional Radiology (SIR) and the Radiologic Society of North America (RSNA) continue to advocate for advanced practice providers within radiology (Taft & Fischer, 2025). Clinical Efficiency and Workforce Utilization The lack of clear legal recognition has resulted in inconsistent utilization of RRAs across radiology departments. As Mezrich (2025) notes, this absence of a standardized legal framework creates compliance concerns that limit how fully radiology groups can integrate these professionals into workflow. Santavicca et al. (2022) also noted that, although Nurse Practitioners (NPs) and physician assistants (PAs) are now common in radiology, RRAs are still limited by state laws and unclear billing policies. These differences from one state to another have made regulation uneven and slowed efforts to create a consistent model for the mid-level radiology provider. Radiology has long operated within a team-based model that includes technologists, nurses, and physicians. The number of radiology practices employing radiology providers increased significantly by 2019, and an estimated 40% of radiologists worked in practices that employed radiology providers (Rawson et al., 2024). Patient satisfaction studies also support the RRA’s value. Sanders (2014) found that patients rated RRAs highly in professionalism and thoroughness. Similarly, a study reported by Dargan (2019) showed a 12-minute reduction in case time when RRAs assisted radiologists during procedures. These findings demonstrate both efficiency and quality-of-care benefits when RRAs are effectively integrated. While the specific scope of practice for RRAs differs by state, these differences uniformly exclude the ability to interpret images or provide a diagnosis. Rawath et al. (2024) pointed out that RRAs can provide value to the peer review program of a busy teleradiology SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 17 practice. Peer review exams involve careful examination of the study, comparing the medical images with the provided report, and alerting the radiologist to any missed findings for further action. During this retrospective study, the authors applied a scoring system based on the ACR RADPEER guidelines to identify discrepancies or irregularities within the radiologists’ reports. The RRAs in this study were able to highlight a 0.53% total of the overall volume of cases that were reviewed, which aligns with the use of artificial intelligence in radiology. While the final decision rests with the radiologists, low rates of clinically significant errors have been achieved with the involvement of RRAs, offering a practical and effective solution to the radiologist crisis (Rawath et al., 2024). Need for National Standardization and Policy Reform Literature consistently supports national standardization of RRA practice and reimbursement policies (Barten et al., 2019; Hart et al., 2021). The Department of Veterans Affairs (2024) addressed the need to have national standards of practice. To ensure, first, that beneficiaries receive the same high-quality care regardless of where they enter the system and, second, that VA health care professionals can efficiently meet the needs of beneficiaries when practicing within the scope of their VA employment. National standards are designed to increase beneficiaries’ access to safe and effective health care, thereby improving health outcomes. (https://www.regulations.gov/document/VA-2024-VACO-0001-0158) This statement is grossly important across all healthcare systems throughout the United States, proving the importance of national standards of practice. The national standards provide, most importantly, safety to all patients and secondly, a clearly defined and understood set of standards to practice regardless of the healthcare setting, facility, or state of practice. A great SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 18 example of the need to create national standards is the Disaster Emergency Medical Personnel that was required during the Covid-19 pandemic. The Department of Veterans Affairs (2024) explains: The increased need for mobility in the VA’s workforce, including through the VA’s Disaster Emergency Medical Personnel System, highlighted the importance of creating uniform national standards of practice to better support the VA health care professionals who practice across state lines. (https://www.regulations.gov/document/VA-2024VACO-0001-0158.) According to the VA system (2024) traveling medical practitioners are highly sought after, especially since COVID-19. While this research is specific to the VA system, it shines light on how this is a barrier to standardization across the nation for all healthcare systems. While 18 States require a license to practice, 14 States exempt federal employees from their state license requirements. The VA suggests following the standards set forth by ASRT and ARRT. Summary Radiology is a fundamental component of modern medical care and having one national scope of practice would make it safer for patients, increase accountability, and help radiology teams work together more effectively and efficiently. It has been addressed that the demand for radiology-led exams is on track to exceed the number of radiologists employed to execute them. RRA’s have extensive training as outlined by the ARRT and can take significant pressure off already strained physicians (ARRT, 2025). By standardizing the scope and capacity at which RRA’s can operate, it will greatly benefit the versatility and continuity of care that they can provide and perform. Integrating the scope at which RRA’s operate will provide seamless mobility across the United States and decrease confusion among employers. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 19 Despite progress, significant inconsistencies persist among states regarding the authorization and recognition of the RRA role. Approximately 17 states still lack formal recognition of RRAs, and limited research exists due to the profession’s relative youth. Consistent, evidence-based standards for training and supervision would keep expectations the same from state to state and create a more reliable workforce. Continued national efforts toward legislative reform and Medicare/Medicaid reimbursement inclusion are necessary to promote consistency and sustainability. In conclusion, this review of literature contributes to supporting ongoing advocacy for a unified RRA role across the United States. Achieving a standardized national scope of practice will strengthen the profession, support equitable access to care, and ensure RRAs can function to the fullest extent of their training. Together, these findings highlight the urgent need for unified national standards to reduce regional disparities, optimize workforce utilization, and ensure patients benefit from the full capabilities of RRA practice. Ⅲ. METHODS AND PROCEDURES Introduction This study employed a mixed-method design to examine variations in scope of practice, utilization, and professional challenges among RA including RRA and RPA across the United States. A mixed-method approach was appropriate because it allowed the collection of both quantitative and qualitative data at a single point in time from a broad group of advancedpractice radiologic professionals. This helped capture current practice patterns, regulatory influences, and the barriers these providers encounter. The design supports quantitative analysis, such as identifying how often certain procedures are permitted, levels of job satisfaction, and the frequency of regulatory or SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 20 institutional restrictions. At the same time, qualitative responses offer deeper insight into practice limitations and professional experiences. Together, this data provides a more complete understanding of regional differences and systemic factors affecting the RA profession. This approach is well aligned with the study’s aims, including determining what RRAs are allowed to do, what tasks they are restricted from performing, and how state and regional policies shape their practice. To complement the survey findings, an online literature review was conducted to identify peer-reviewed research, professional guidelines, and policy documents related to RRA's scope of practice and utilization. Graduate students at Weber State University’s Radiologic Sciences program conducted a literature search using the Weber State University library resources, employing systematic search techniques. Searches were completed between September and November 2025 using academic databases including PubMed, Google Scholar, and the Journal of the American College of Radiology. Sources included certification standards, practice guidelines, and position statements from major organizations such as the American College of Radiology (ACR), the American Registry of Radiologic Technologists (ARRT), and the American Society of Radiologic Technologists (ASRT). Key peer-reviewed studies by Barten et al. (2019), Christensen et al. (2025), and Dargan (2019) were also reviewed, and the reference lists of relevant publications were also examined to identify additional relevant material. Population The target population for this study consists of advanced-practice providers in radiology who currently hold RA/RRA/RPA credentials and are practicing within the United States. These individuals complete a general radiologic technology training program, learning the SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 21 fundamentals of radiation safety, how to perform high-quality diagnostic radiology exams, and provide compassionate patient care. A more precise inclusion and exclusion data of the population highlighted the contrast of an advanced practice provider with radiology privileges vs. an advanced practice provider with a concurrent radiology background (i.e. RRA/RPA). The population chosen to be surveyed accurately represents the role as a functioning RA/RRA/RPA The inclusion population includes: ● RRAs credentialed through ARRT ● RPAs credentialed through Certification Board of Radiology Practitioner Assistants (CBRPA) ● Individuals functioning in RA-equivalent roles under radiologist supervision ● Practicing RAs across hospitals, outpatient, academic, and private group settings The exclusion population includes: ● PAs specializing in radiology ● PAs with an ARRT license (CT/MRI/Sonography i.e.) ● Nurse Practitioners (NP) trained in radiology ● Any mid-level provider in radiology outside of RRA/RPA PAs are licensed clinicians who practice medicine in every specialty and setting. They are required to have an undergraduate degree in a nonspecific field, followed by completion of a graduate level PA program. Although PA’s rotate through a variety of clinical specialties during training, there is no mandatory radiology specific training. A NP is an advanced practice registered nurse and a type of mid-level practitioner. Like the PA role, the bulk of their training is not confined to the radiology department as they are a SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 22 broad mid-level ranging over numerous specialties. The population was defined broadly to ensure representation from multiple regions and to reflect the different titles and credentialing routes used for advanced-level radiologic practitioners from across the country. PAs and NPs working in Radiology departments, who do not have a radiology training background and do not have an advanced degree in radiology, were excluded. All survey participants were adults over the age of 18. The sampling strategy used is non-probability sampling, specifically purposive sampling. This approach allowed us to target a population of individuals with specific credentials and backgrounds. Focusing on those currently practicing as RRAs and other individuals holding equivalent roles. Instrumentation Survey instrumentation was chosen due to the ease and accessibility of questions. The survey (see Appendix A) developed specifically by the researchers was used to assess variations in the scope of practice, institutional utilization, perceived barriers, and job satisfaction among RRAs. Survey questions were chosen based on existing literature about RRA regulation, professional practice standards from ARRT and ASRT, and prior workforce studies in radiology such as Perceptions and Current Practices of Radiologist Assistants’ Peer Review Process by Dillard and Matthews (2024) and other advanced practice professions. The survey included a combination of 12 closed-ended questions divided into 8 multiple-choice, 2 check-all-that-apply, 2 Likert scales. The Likert scales measure the level of satisfaction for different topics in a 1 (Not Satisfied at all), 2 (Dissatisfied), 3 (Neutral), 4 (Satisfied) to 5 (Very Satisfied) system. At the end of the survey were 3 open-ended questions designed to capture detailed, qualitative insights. Each question was split into categories based on the ARRT CR-1 form (See Appendix C). This SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 23 allowed for an accurate representation of each specific limitation RRAs are facing and avoided potential confusion between which exams the survey is questioning. The survey consisted of four major domains: 1. 10 questions regarding background and demographic information, including job title, practice setting, state/region, and years of clinical experience. 2. 2 questions regarding scope of practice and procedural authority, documenting what tasks participants are permitted to perform and any restrictions they experience. (See Appendix C for procedural list from ARRT) 3. 1 question regarding barriers and institutional/regulatory influences, such as state legislation, reimbursement policies, and employer-specific limitations. 4. 3 questions regarding job satisfaction and professional perspectives, including perceived challenges and overall satisfaction with the RRA profession. 5. 3 open ended questions about challenges in their role, role improvement and role restrictions. Draft questions were reviewed for content relevance, clarity, and alignment with the study objectives. The final questions were formatted using the online survey, created and administered via Qualtrics (Provo, UT). The survey was estimated to take participants 10 minutes to complete and submit. Each question was split into categories based on the ARRT CR-1 form, allowing for an accurate representation of each specific limitation RRAs are facing, and avoiding potential confusion between which exams the survey is questioning. Prior to sending out the survey and collecting data, we received approval from the IRB of Weber State University on April 19, 2026. The online survey was delivered electronically SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 24 through Qualtrics (Provo, UT). The link to participate was distributed via email (See Appendix D) to participants with appropriate credentials collected from ASRT and ARRT and posted on the Facebook group for Society of Radiology Physician Extenders. There was also an informational letter (See Appendix E) participants could read for further information on the study. This instrumentation method provided quick and easy access for participants and immediate data collection. Data review and data cleaning began on Thursday, June 4, 2026. Statistical analysis began the following week. The survey was open on Wednesday, April 22, 2026, and closed on Wednesday, June 3, 2026. At the closing of the survey, we had 87 responses. 81 of those were filled out enough to be used in our statistical analysis. The 6 deleted were due to 4 having incomplete responses and 2 being left blank. Research was properly evaluated and the data analyzed during the 2026 summer semester to ensure adequate time for a thorough review. Validity and Reliability Ensuring the validity and reliability of the study was crucial for producing trustworthy results regarding regional differences in the scope of practice for the RRA Several planned steps enhanced the accuracy of the survey instrument and the stability of the findings. Content validity was ensured by developing the survey questions from established professional standard and regulatory guidance, including the ARRT scope of practice, ASRT practice standards, state regulatory language, and published research on advanced radiologic practice roles. Using these materials helped guarantee that the survey addresses the essential areas relevant to this study, such as supervision expectations, procedural responsibilities, and regulatory limitations. Rickards et al. (2012) note that grounding survey questions in established SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 25 standards strengthens content coverage and improves the likelihood that the items represent the concepts being examined. Face validity was strengthened by having graduate students and in radiologic sciences review the draft survey. Although they are not subject-matter experts, these students work in radiology settings and are familiar with daily workflow and the typical responsibilities of RRAs. This experience allows them to identify questions that may be unclear, confusing, or misaligned with the study’s objectives. Their feedback ensured that the survey is clear and relevant to the intended audience. Rickards et al. (2012) emphasize that having individuals familiar with the field review the study is a practical step for improving clarity and reducing avoidable errors in self-report instruments. There was also a panel of experts in the field of Radiological Sciences reviewing the draft survey including Dr. Laurie Coburn who is also credentialed as a RRA. Construct validity was examined by assessing whether different types of questions converge on the same general themes. If both rating-scale items and open-ended responses reveal similar patterns, it indicates that the survey is effectively measuring the concepts it was designed to capture. Artino et al. (2014) emphasizes comparing the behavior of different items is a crucial step in assessing whether an instrument accurately reflects the underlying ideas it aims to measure. Rickards et al. (2012) also note that related questions should yield predictable and consistent responses when a survey is well-designed. Triangulation further supported validity by comparing survey findings with external sources such as state statutes, national organization guidelines, and published research. Poghosyan et al. (2015) explain that triangulation strengthens the credibility of results when survey responses align with documented policies or established evidence. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 26 Reliability was supported through consistent survey formatting, parallel question structure, and standardized response options. Maintaining similar wording and scale anchors helped reduce variability in how participants interpret the items. After data collection, internal consistency was analyzed using Cronbach’s alpha. For qualitative data, reliability was strengthened through an inter-rater review process. At least two team members coded the open-ended responses independently and compared their interpretations. Any differences were discussed and resolved collectively. Poghosyan et al. (2015) note that the use of multiple coders reduces individual bias and improves the dependability of qualitative findings. These procedures collectively ensured the accuracy, clarity, and consistency of the survey instrument, thereby bolstering confidence in the study’s results. Data Collection According to our consent form (See Appendix B), all participants answered survey questions voluntarily and were advised that some questions are personal and may evoke discomfort. All details of the study were clearly explained within the consent form in a comprehensible manner to ensure complete understanding. The primary method for disseminating each survey was through word of mouth. The researchers in this project consist of seventeen students and one doctoral-level professor. Each student was asked how many RPAs/RRAs they work with. The approximate number of RPAs/RRAs available to conduct this survey within the students' personal network was thirty-one. The demographics of each student are spread across the United States, divided into 4 main regions: the Northeast, the Midwest, the South, and the East. There are six students in the Midwest, six students in the South, five in the East, and zero in the Northeast. Due to the regional variance of the study, the data that was SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 27 convenient and snowball sampling provided a broad range of samples. Throughout these intrapersonal networks, each student had the opportunity to request the RPAs/RRAs to reach out to other colleagues who may also be interested in taking the survey. This helped encourage diversity among participants and facilitate the use of larger datasets. As a secondary data collection, professional society, the Society of Radiology Physician Extenders (SRPE) was surveyed to increase the number of participants, once the proper permission was granted. Each survey was online and walked participants through the consent form. Participants were informed that their responses would remain anonymous and that participation was voluntary, allowing them to discontinue the survey at any time. The consent covered the benefits and risks of this survey. Participants were provided with a point of contact on the consent form in case questions or concerns arise. The survey was estimated to take participants 10 minutes to complete and submit. Each question was split into categories based on the ARRT CR-1 form, allowing for an accurate representation of each specific limitation RRAs are facing, and avoiding potential confusion between which exams the survey is questioning. Research was properly evaluated based on the voluntary responses given within a specific timeframe. The survey was available once the IRB had given the appropriate approval notice. After the IRB approved the proposal, students were allowed to view current responses online using the link at Qualtrics.com. The data was analyzed during the 2026 summer semester to ensure adequate time for a thorough review. Data Analysis Open-ended survey questions were used in inductive methods to lead to a thematic analysis regarding the RRA variation across the United States. This approach relies on preexisting knowledge of the RRA profession from the literature review and on identifying SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 28 survey patterns from RRA real-world experiences. Responses included information regarding role restrictions, procedures permitted, and challenges faced by those practicing in the RRA field. Conclusions were made based on these results (Jacobsen, 2020). Survey results were filtered for accuracy, with incomplete or duplicate responses removed. The self-administered survey, which included fixed-response quantitative answers and multiple-choice questions, was used to deduce job satisfaction, experience, primary practice settings, clinical tasks performed, limitations in practice, and recommendations for future career prospects. Statistical data regarding RRAs current clinical abilities and restrictions in varying parts of the country was compared to the literature review to determine if theories regarding the profession are accurate. Through sampling, an observed score was assigned to closed-ended answers. The observed score provided an insight into the demographic information, skillset, barriers, and experiences of RRA’s. Based on the answers received, representative sampling was used to provide an understanding of these topics. As previously mentioned, the collected data was screened for reliability and validity. If the responses did not meet the criteria of the study, the responses were disregarded. Once confirmed, variables were assigned to answers, then the correlation between responses was evaluated. T-tests and ANOVA tests were used to compare collected information. Correlations between variables may show positive or negative relationships, and conclusions can be drawn based on the correlation direction. In this study, oneway ANOVAs were conducted to determine whether total scope-of-practice scores differed significantly based on geographic region, years of experience, and level of physician supervision. Qualitative data complemented statistical data to support or contradict predictions. These answers will provide the opinions and experiences of RRA’s practicing in the radiologic field SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 29 (Jacobsen, 2020). Using a mixed-methods approach allowed for the collection of both quantitative and qualitative data concurrently. This convergent design gathered both types of data concurrently and was examined and integrated into the results. Combining methods provided an understanding of the factors affecting utilization of RRA’s (Jacobsen, 2020), with a goal of providing a deeper understanding of the RRA scope of practice variation across the United States. Findings provided potential solutions or strategies for future action. Ethical Considerations This study involved minimal risk and adhered to standard ethical guidelines for human subjects research. Participants were informed of the study’s purpose, procedures, and voluntary nature through an online informed consent form presented before accessing the survey. Only individuals who electronically agree to participate were allowed to proceed. Confidentiality was protected by collecting data anonymously. No identifying information, such as names, email addresses, or IP addresses, was requested or stored. Responses were reported only in aggregate form, ensuring that no individual participant or institution can be identified. Potential risks for participants were low and primarily relate to the possibility of discomfort when describing workplace restrictions or professional challenges. Participants could skip any question or withdraw at any time without penalty. All data was stored securely on password-protected systems accessible only to the research team. The full study protocol, including the survey instrument and recruitment procedures, was submitted to the Institutional Review Board (IRB) for review and approved prior to data collection. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 30 IV. Statistical Analysis and Results Introduction This study was a mixed methods design that examined variations in scope of practice, utilization, and professional challenges among RAs, including RRAs and RPAs, across the United States. A mixed-method approach was appropriate because it allowed the collection of both quantitative and qualitative data at a single point in time from a broad group of advancedpractice radiologic professionals. This helped capture current practice patterns, regulatory influences, and the barriers these providers encounter. The survey included a combination of 12 closed-ended questions (multiple-choice, check-all-that-apply, and Likert scales) and 2 open-ended questions. One-way ANOVAs and qualitative analysis using an inductive approach were the two types of stats run on SPSS. Demographics The current job titles of our survey participants included 17 RPA, 62 RRA, and 2 RA, see Table 1. Of all the respondents, 96% are currently employed under their respective titles, and 4% are not. This leads us to believe that we have received the opinions of people who are working in the field and currently experiencing the challenges faced in the RRA profession. Table 1 Current Job Title Title N % Radiologist Assistant (RA) 2 2.5% Radiology Practitioner Assistant (RPA) 17 21.0% Registered Radiologist Assistant (RRA) 62 76.5% Total 81 100% SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 31 Scope of practice limitations for RRAs begin at the state level. 30 states were represented in this survey, allowing us to better understand how the challenges differ and compare in those states. The remaining demographics will be addressed in research questions because they are a part of some of the independent variables. Research question 1: How does the scope of practice vary across regions? Research Question 1 examined whether the scope of practice of RRAs differed across geographic regions. A one-way analysis of variance (ANOVA) was conducted using geographic region as the independent variable and total scope of practice as the dependent variable. The geographic region was categorized into the Northeast, Southeast, Midwest, Southwest, and West regions. Total scope-of-practice scores were calculated by summing the clinical tasks and procedures that respondents reported being authorized to perform. A higher total scope-ofpractice score indicated that an RRA was authorized to perform a greater number of procedures and therefore represented a broader scope of practice, whereas a lower score indicated authorization to perform fewer procedures and a more limited scope of practice. Examination of the dependent variable indicated a slight negative skew in total scopeof-practice scores (skewness = −0.790), whereas kurtosis was within acceptable limits (kurtosis = 0.068). Given the sample size (N = 76), the one-way ANOVA was considered robust to this minor violation of normality. As indicated in Table 2, the one-way ANOVA demonstrated that there were no statistically significant differences in total scope-of-practice scores among the five geographic regions, F(4, 71) = 0.724, p = .578, ω² = .000. As shown in Table 3, descriptive statistics revealed that participants practicing in the Southwest reported the highest mean total scope of practice score (M = 5.83, SD = 1.17), whereas those practicing in the Midwest reported the lowest mean score (M = 4.95, SD = 1.23). SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 32 Therefore, the null hypothesis was retained, suggesting that geographic region was not associated with differences in RRA scope of practice within this sample. These findings indicate that factors other than geographic location may play a greater role in influencing RRA utilization and scope of practice. Table 2 Descriptive Statistics for Total Scope of Practice by Geographic Region Region N M SD Northeast 20 5.50 1.85 Southeast 20 5.55 1.50 Midwest 20 4.95 1.23 Southwest 6 5.83 1.17 West 10 5.10 1.29 Total 76 5.34 1.48 Table 3 One-Way ANOVA Examining Differences in Total Scope of Practice by Geographic Region Source Sum of Squares df Mean Square Between Groups 6.472 4 1.618 Within Groups 158.633 71 2.234 Total 165.105 75 F Sig. 0.724 0.578 Note. ω²=.000 Research question 2: Do years of experience affect the scope of practice? SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 33 Question two evaluated if years of experience affected scope of practice. A one-way ANOVA was conducted to examine whether the scope of practice differed based on years of experience. Participants were grouped into three categories: 0=5 years (n=24), 5-10 years (n=10), and more than 10 years (n=42). Results indicated that there was no statistically significant difference in scope of practice scores among the three experience groups, F (2,72) =0.19, p=.824, ω²=.00. See Table 4 for descriptive statistics distributed by percentage of respondents and Table 5 for descriptive statistics grouped into years of experience. These findings suggest that years of experience did not significantly affect the scope of practice in this sample. Table 4 Distribution of Respondents by Years of Experience (N = 76) Years of Experience n % 0-5 years 24 31.6 5-10 years 10 13.2 More than 10 years 42 55.3 Total 76 100.0 Table 5 Descriptive Statistics by Years of Experience (N = 76) Years of Experience n M SD 0-5 Years 24 5.25 1.39 5-10 years 10 5.60 1.43 More than 10 years 42 5.33 1.57 Total 76 5.34 1.48 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 34 Research question 3: How does level of supervision affect scope of practice? For question 3, a one-way ANOVA was run to determine if there were significant differences in scope of practice based on level of physician supervision. There was no significant difference between supervision levels in scope of practice, F (2, 73) = 0.084, p = .920. Although the omnibus test was non-significant, these findings suggest that level of physician supervision does not meaningfully influence the scope of practice of radiologist assistants. See Table 6 for descriptive statistics by group. Table 6 Descriptive Statistics by Group Level of supervision N Mean Std. Deviation Std. Error Direct (Physician immediately available) 43 5.30 1.57 .239 General (Physician within building) 28 5.43 1.48 .279 Personal (Physician in procedure) 5 5.20 0.84 .374 Total 76 5.34 1.48 .170 Research question 4: How does the interaction of primary practice settings affect job satisfaction? We performed a one-way ANOVA to determine whether there were significant differences in job satisfaction across primary practice settings, including hospitals, outpatient imaging centers, academic medical centers, and private radiology groups. The dependent variable, job satisfaction, is negatively skewed (skew = -.636, SEskewness = .283) and slightly platykurtic (kurtosis = -.709, SEkurtosis = .559): most participants rate their job satisfaction as SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 35 high, while only a few rate it near the lower end of the scale. There was a significant difference in job satisfaction across different primary practice settings (F3,68 = 3.67, p = .016, ⍵2 = .10). Approximately 10% of the variance in job satisfaction can be attributed to different primary practice settings. See Table 7 for descriptive statistics by group. To follow up on the significant omnibus test, we used Tukey post-hoc test to determine how job satisfaction varied in primary practice settings. There was not a significant difference between all post-hoc comparisons: Job satisfaction between hospital and outpatient imaging center (p = .056), hospital and academic medical center (p = .390), hospital and private radiology group (p = .152), academic medical center and outpatient imaging center (p = .878), private radiology group and outpatient imaging center (p = .825), and academic medical center and private radiology group (p = 1.00). Overall, primary practice settings significantly affected participants’ job satisfaction, with varied levels of satisfaction across settings. Table 7 Descriptive Statistics by Group Primary Practice Setting N M SD SE Hospital 48 4.06 .68 .098 Outpatient Imaging Center 6 4.78 .27 .11 Academic Imaging Center 6 4.50 .78 .32 Private Radiology Group 12 4.50 .54 .16 Total 72 4.23 .68 .08 Research question 5: How does the interaction of the practice region affect job satisfaction? SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 36 After performing a one-way ANOVA to determine whether job satisfaction differed significantly across regions (Northeast, Southeast, Midwest, Southwest, and West). There was no significant difference in job satisfaction by region (F4,67 = 1.72, p = .156, w2 = .038). See Table 8 for descriptive statistics of job satisfaction by region. In conclusion, the overall mean job satisfaction across all regions was 4.23 on a 5-point scale (1 = not at all satisfied, 5 = very satisfied). These findings suggest that job satisfaction levels were generally consistent across regions, with no significant regional differences observed in this sample. Table 8 Descriptive Statistics by Region Region N M SD SE Northeast 20 4.40 .568 .127 Southeast 19 4.02 .842 .193 Midwest 18 4.22 .686 .162 Southwest 6 4.67 .298 .122 West 9 4.00 .553 .184 Total 72 4.23 .680 .080 Research question 6: How does the interaction of salary range affect job satisfaction? A one-way ANOVA was performed to determine if there was a significant difference in job satisfaction based on salary, with salary ranges of 71,000-90,000, 91,000-120,000, and 121,000+. The results indicated a statistically significant difference in job satisfaction across salary groups, (F2, 68 = 4.20, p = .019, ω² = .083). The effect size was small to moderate, indicating that salary range explained approximately 8.3% of the variance in job satisfaction. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 37 Participants earning $121,000 or more reported the highest job satisfaction (M = 4.35, SD = .621), followed by participants earning $91,000–$120,000 (M = 3.96, SD = .740). The participant earning $71,000–$90,000 had a job satisfaction score of (M = 3.00). In addition, SPSS did not perform post-hoc tests on the lowest salary group because there were fewer than two cases. Although the overall ANOVA was statistically significant, it was not possible to determine which specific salary groups differed significantly from one another. The results should also be interpreted with caution due to the extremely small sample size in the lowest salary category. See Table 9 for descriptive statistics by salary group. Table 9 Descriptive Statistics for Job Satisfaction by Salary Range Salary range N M SD SE $71,000- $90,000 1 3.0 N/A N/A $91,000- $120,000 18 3.96 .740 .174 $121,000+ 52 4.35 .621 .086 Total 71 4.23 .682 .081 Note. Standard deviation and standard error were not calculated for the $71,000–$90,000 group because only one participant was in that group. Qualitative analysis of the open-ended participant responses Quantitative results show there is no significant difference in the scope of practice across regions, years of experience, supervision level, or job satisfaction. However, qualitative analysis of the open-ended participant responses revealed several recurring themes related to the challenges, restrictions, and future development of the RRA profession. An inductive approach SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 38 was used to organize responses into themes. The qualitative section enhances the quantitative findings by revealing additional themes and perspectives, providing a more comprehensive understanding of the results. Despite the consistency of the RRA role across regions, challenges for full utilization persist. The most frequently cited challenges involved role recognition, reimbursement and billing limitations, supervision requirements, and scope-of-practice restrictions. See Table 10 for participant responses supporting the identified themes. Participants consistently reported that healthcare professionals, administrators, technologists, patients, and the public often lack understanding of the RRA role. This lack of awareness contributed to difficulties obtaining professional recognition, achieving equal standing with other advanced practice providers, and fully utilizing their skills within healthcare organizations. Table 11 presents the frequency of identified challenges. The most reported challenge was professional recognition (n = 20, 35.1%), followed closely by scope-of-practice and supervision concerns (n = 18, 31.6%) and reimbursement and billing limitations (n = 17, 29.8%). These findings suggest that barriers related to professional visibility, autonomy, and financial sustainability are among the top concerns in the profession. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 39 Table 10 Challenges Faced by R.R.A.’s Theme Key Themes Emerging from Participant Responses Reimbursement, Billing, "Hospital credentialing is limiting my scope of practice, and there is a and Regulatory Barriers lack of reimbursement for my cases." "Federal Billing restrictions."; "Medicare reimbursement." Lack of Professional "General populations' lack of understanding of my job title."; Recognition and Role "Hospital recognition that we are mid-level providers."; "Not being seen Awareness as a mid-level provider by technologists or other medical professionals." Scope of Practice and "Not able to work without a radiologist being in the building." Supervision Restrictions "Supervisory restrictions."; "Limited scope." Role Expansion and "Not able to increase skill set due to lack of reimbursement." Underutilization "We could likely do more and help the department be more efficient."; "My role would expand greatly with the ability for the radiologist to bill for my work." Comparison and "PA or NP joining the team as a radiologist assistant type role." Competition with other "Acceptance. Encroachment from other APPs." APPs "Unable to do procedures I'm trained for and seeing PAs take over our roles." Staffing, Workload, and "Maintaining the volume of daily work." Coverage Concerns "I am the only RPA/RRA in my practice." SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 40 Table 10 cont Theme Key Themes Emerging from Participant Responses Workplace Support and "Workload facility expectations vs radiologist expectations." Administrative "Not enough support from radiologists when I am extremely busy." Challenges Variability in "Some radiologists prefer to do all procedures themselves whereas Institutional and others let me do whatever I'd like."; "My radiologists completely support Radiologist Support the role of the RA."; "Colleagues understanding the scope of my practice and radiologists supporting the full scope of my practice." State Legislative and "State laws."; "Lack of guidelines within the state level."; Credentialing Barriers "Hospital credentialing limiting my scope of practice." SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 41 Table 11 Descriptive Statistics of Challenges in the Profession Challenge n % Recognition 20 35.1 Scope/Supervision 18 31.6 Billing 17 29.8 Staffing and Coverage 7 12.3 Administrative Challenges 6 10.5 Role Expansion 5 8.8 APP Competition 4 7.0 State Laws and 4 7.0 2 3.5 Credentialing Positive Institutional Support Note: Percentages may exceed 100% because respondents can identify multiple challenges. Another common theme involved reimbursement and regulatory barriers, particularly the lack of recognition by the Centers for Medicare and Medicaid Services (CMS). Respondents frequently described the inability to bill independently as the profession's greatest obstacle, noting its impact on compensation, hiring opportunities, role expansion, and long-term sustainability. Participants expressed frustration that reimbursement limitations often prevented institutions from fully utilizing RRAs despite their training and demonstrated competence. Billing and reimbursement limitations were identified by nearly one-third of respondents (29.8%), making this one of the profession's most significant concerns. Legislative barriers, SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 42 including state-specific regulations and delays in professional recognition initiatives, were also identified as significant factors limiting professional growth. Participants also described substantial practice restrictions resulting from hospital policies, supervision requirements, and credentialing processes. As shown in Table 12, procedural limitations were the most frequently reported restrictions, identified by 83.3% of respondents who discussed restrictions. Institutional policies (50.0%) and physician supervision requirements (33.3%) were also commonly mentioned. Most respondents reported being unable to perform procedures for which they were trained due to requirements for direct radiologist supervision, restrictive institutional policies, or limitations imposed by credentialing bodies. Most participants noted that conservative hospital environments and radiologist-on-site requirements reduced procedural autonomy and limited their ability to contribute to departmental efficiency. In many settings, responsibilities traditionally associated with the RRA role were instead assigned to nurse practitioners or physician assistants, creating concerns regarding role overlap and professional encroachment. Table 12 Descriptive Statistics of Professional Restrictions Restrictions n % Procedural Limit 5 83.3 Institutional Policy 3 50.0 Physician Supervision 2 33.3 APP overlap 16.7 1 Note: Percentages may exceed 100% because respondents can identify multiple restrictions. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 43 Despite these challenges, respondents expressed strong enthusiasm for the profession and identified several opportunities for future growth. Themes related to professional advocacy, education, and role visibility emerged frequently. As shown in Table 13, legislative advocacy emerged as the most frequently suggested strategy for improving the profession (n = 10, 35.7%), followed by increased professional recognition (n = 7, 25.0%) and addressing competition from other advanced practice providers (APPs) (n = 6, 21.4%). Participants emphasized the need for increased awareness of RRA education, training, and the scope of practice among healthcare professionals, administrators, and the public. Many also highlighted the importance of developing additional educational programs, strengthening recruitment efforts, and fostering greater unity within the radiology profession. Several respondents described teaching radiology residents and mentoring future practitioners as particularly rewarding aspects of their roles. Table 13 Descriptive Statistics of Suggestions to Improve Profession Role Improvement n % Legislative Advocacy 10 35.7 Professional Recognition 7 25.0 APP competition 6 21.4 Workforce Development 5 17.9 Job Satisfaction 5 17.9 Compensation 4 14.3 Scope Expansion 3 10.7 Note: Percentages may exceed 100% because respondents can identify multiple improvements. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 44 Finally, participants identified scope expansion, professional recognition, and workforce development as essential priorities for the future of the profession. Respondents expressed interest in performing more interventional and vascular procedures and advocated recognition equivalent to that of other advanced practice providers. Most believed that achieving CMS recognition and resolving reimbursement challenges would significantly improve career opportunities, compensation, and job availability while helping preserve radiology-specific expertise within imaging departments. Overall, while respondents reported high levels of job satisfaction when working in supportive environments, they viewed increased recognition, reimbursement reform, and expanded practice opportunities as critical to the continued advancement of the RRA profession. Discussion The findings of this study identify variations in the RRA scope of practice and utilization across the United States. While the profession was established to enhance radiology workflow efficiency, improve patient access to imaging services, and support radiologist-led care (Williams & Short, 2004; American Society of Radiologic Technologists [ASRT], 2002), the degree to which RRAs are utilized remains heavily influenced by state-specific regulations, institutional policies, reimbursement limitations, and differences in physician acceptance. The statistical results for the quantitative questions showed no significant differences in the scope of practice being affected by region, years of experience or level of supervision. Nor was there a significant difference in the level of job satisfaction when it comes to the scope of practice or the practice region. However, we did see a significant difference in job satisfaction and the primary practice setting as well as job satisfaction and the salary range. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 45 Although many of the quantitative research questions did not show significant differences in an RRA's ability to perform a job, the open-ended responses offer a greater depth regarding participants' concerns. The responses revealed themes and experiences that may not have been reflected in the quantitative findings alone. These results from the open-ended participant responses suggest that the absence of a standardized national scope of practice has contributed to inconsistencies in role implementation, creating barriers that limit the full utilization of qualified RRAs despite the growing workforce demand. Their roles and advanced skills are often underutilized, leading to encroachment on their scope by other advanced practice providers. This concern is consistent with literature describing the RRA as a highly specialized radiology extender whose advanced education and clinical training are specifically designed to support radiologists and expand the efficiency of the radiologist-led team (American College of Radiology [ACR], 2021). The literature therefore supports the concern that failure to fully utilize these specialized competencies may limit the intended contribution of the RRA role within radiology practice. These results show that job satisfaction, practice setting, demographics, years of experience, and salary range do not significantly affect an RRA’s ability to perform their role. However, scope of practice, supervision concerns, reimbursement limitations, and other professional barriers are the most commonly reported challenges affecting recognition and utilization of the profession.This finding is supported by prior literature showing that barriers to RRA utilization have persisted despite the profession’s development as an advanced clinical role intended to improve radiology workflow and extend the capabilities of the radiologist-led team (Williams, 2004). More recent professional literature similarly identifies reimbursement as a continuing obstacle to the effective utilization of RRAs, particularly because radiology practices SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 46 have historically been unable to receive Medicare reimbursement for certain services performed by RRAs in facility settings (ACR, 2021). Although physician supervision requirements are often cited as a barrier to RRA practice, this study found no significant relationship between supervision level and reported scope of practice. This finding suggests that efforts to improve RRA utilization should focus less on supervision models and more on addressing legislative, reimbursement, and organizational barriers that participants consistently identified as limiting the profession.The lack of a significant association with supervision in the present study is particularly important when considered alongside literature emphasizing that the RRA role was intentionally developed to function under radiologist supervision rather than as an independent practice model (ACR, 2021). This suggests that the presence of supervision itself may be less restrictive than the regulatory, institutional, and reimbursement structures that determine which RRA services can actually be performed and supported within clinical practice. This interpretation is consistent with national advocacy efforts emphasizing that reimbursement policy and legislative recognition remain the principal barriers to broader implementation of the RRA role. The American College of Radiology has stated that MARCA is intended to address these barriers by establishing Medicare reimbursement for services performed by Registered Radiologist Assistants within a radiologist-led model of care, while the American Society of Radiologic Technologists continues to identify reimbursement and inconsistent state recognition as significant barriers to full utilization of the profession. Current advocacy efforts further reinforce the findings of this study. The ACR (2026) has stated that although Medicare recognizes RAs for certain diagnostic imaging services under radiologist supervision, practices remain unable to submit Medicare claims for some procedures and other SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 47 services performed by RAs in facility settings. Similarly, the ASRT (2026) maintains that MARCA would allow services provided by RAs under radiologist supervision to receive Medicare reimbursement across multiple practice settings, thereby allowing RAs to be more fully utilized within radiologist-led teams. These findings are also consistent with the original development of the RRA role, which recognized that legislative and regulatory support would be essential for successful implementation (Williams, 2004). Taken together, the literature and the findings of the present study suggest that many of the challenges identified during the early development of the RRA profession remain relevant today, particularly those involving reimbursement, regulatory recognition, institutional acceptance, and the ability to fully utilize the advanced clinical skills for which RRAs are educated and credentialed. These findings align with previous literature indicating that healthcare professionals practicing in advanced clinical support roles often face challenges related to regulatory fragmentation and variable state oversight. According to the American Society of Radiologic Technologists (2002), the Advanced Practice Advisory Panel met in Washington, D.C., to discuss key issues surrounding the development of an advanced clinical role for radiologic technologists. More than two decades later, participants in the present study continue to identify many of these same barriers, suggesting that progress has been made but that important legislative and organizational challenges remain. Recent legislative efforts further demonstrate that these challenges persist. In 2026, the Medicare Access to Radiology Care Act (MARCA) was reintroduced in Congress with the support of the American College of Radiology (ACR), the American Society of Radiologic Technologists (ASRT), the American Registry of Radiologic Technologists (ARRT), and the Society of Radiology Physician Extenders (SRPE). The legislation seeks to establish Medicare reimbursement for services performed by Registered SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 48 Radiologist Assistants under radiologist supervision, reflecting continued national recognition that reimbursement and legislative barriers remain among the primary factors limiting full utilization of the profession (American College of Radiology, 2026; American Registry of Radiologic Technologists, 2026). Similar to other allied health professions, RRAs encounter disparities in practice authority that affect both professional mobility and healthcare organizations' ability to maximize workforce efficiency. The variation identified in this study highlights the complex interaction between state legislation, organizational policies, and reimbursement structures, all of which influence how RRAs contribute to patient care. These findings are also consistent with the national survey by Barten et al. (2019), which reported that RRA utilization is influenced more by state regulations, employer policies, and reimbursement practices than by differences in education or competency. One of the most commonly reported barriers among participants was the lack of reimbursement and national recognition for the RRA profession. These findings are consistent with previous literature indicating that reimbursement policies and physician supervision requirements continue to influence the utilization of RRAs in clinical practice (Greeson & Pitts, 2011). Despite the advanced education and clinical training required for RRA certification, reimbursement restrictions continue to limit employment opportunities and prevent many healthcare organizations from fully utilizing these professionals. This reimbursement barrier has been recognized by multiple national radiology organizations as a significant obstacle to broader implementation of the RRA profession. The ACR has emphasized that the absence of a Medicare reimbursement mechanism limits the ability of healthcare organizations to fully utilize Registered Radiologist Assistants, despite their advanced education and demonstrated ability to SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 49 improve workflow and patient access to imaging services (American College of Radiology [ACR], 2026). Current advocacy efforts surrounding the MARCA act seek to establish Medicare reimbursement for services performed by qualified RRAs under radiologist supervision, which could improve workforce utilization and expand patient access to imaging services (American Society of Radiologic Technologists [ASRT], n.d.; American Registry of Radiologic Technologists [ARRT], 2025). Similarly, the American Registry of Radiologic Technologists (ARRT) has identified MARCA as a legislative priority, noting that the bill would establish Medicare reimbursement for qualified RRA services while preserving the radiologist-led model of care (American Registry of Radiologic Technologists [ARRT], 2026). The concerns expressed by participants in this study suggest that continued legislative efforts and reimbursement reform remain essential to advancing the profession and ensuring that RRAs are utilized to the full extent of their education, training, and scope of practice. These results suggest that policy differences may have broader implications for healthcare access and operational efficiency. In states where RRAs are granted greater practice flexibility and institutional support, healthcare systems may be better positioned to address increasing imaging volumes and radiologist workforce shortages (Christensen et al., 2025; Rawson et al., 2024). Restrictive policies may limit opportunities for role expansion and reduce the potential benefits of RRA integration into radiology practices. As imaging demand continues to increase nationwide, optimizing the utilization of qualified RRAs may improve workflow efficiency, expand patient access to imaging services, and allow radiologists to focus on more complex diagnostic and interventional responsibilities. Conclusion SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 50 This study demonstrated that statistically significant differences in RRA scope of practice were not identified based on geographic region, years of experience, or level of physician supervision but statistically significant differences were identified for job satisfaction based on practice setting and salary. The qualitative findings revealed substantial variability in RRA utilization across clinical practice. Participants consistently identified barriers related to reimbursement, state regulations, institutional policies, physician acceptance, and limited awareness of the RRA role. These findings suggest that organizational and legislative factors may play a greater role in RRA utilization than demographic characteristics alone. Implications of Results for Evidence-Based Practice Evidence-based practice is the standard in health care for quality patient care. Based on the results of this study, the implications can have a profound positive impact on the RRA role within the healthcare system, which, in turn, will have a profound positive impact on the patient. Expanding the evidence surrounding the utilization of RRAs can increase their implementation as a known and accepted healthcare role, leading to informed decision-making and legislative advocacy. Increased use of RRAs has the potential to improve workplace efficiency, leading to reduced delays in patient care, enhanced patient care, and greater employee satisfaction. Limitations This study is based on a survey questionnaire as the primary method of data collection. As with any survey research, there are several limitations to consider. This can include low response rates, potential bias from participants, and challenges that come with self-reported data. Even with these limitations, the results of this study will hold valuable insight into the existing knowledge base by addressing inconsistencies within healthcare facilities regarding the scope of SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 51 practice for RRAs. This research aims to support greater professional equality and promote consistency in the role of RRAs moving forward. According to the Society of Radiology physician extenders, there are 660 RRAs in the United States. Our survey only reached 87 RRA. Though the responses we received were very informative, they only represent 13% of the target audience. Only one respondent was from the west coast. It is unclear whether this lack of response reflects limitations in our network's ability to reach RRAs in these states or factors affecting RRA employment in these states. Future research targeting RRAs working in these states specifically may expand our understanding of the RRA experience nationwide. Many RRAs responded to open-ended questions by describing limiting factors within their scope of practice or factors that negatively affect their job satisfaction, which we did not include in formal survey questions. Future researchers may consider expanding survey questions to gather more quantitative data on these factors. Future Research Our hope is that this thesis raises awareness of the challenges faced by RRAs in their field and that these challenges can be further assessed and ultimately reduced, thereby decreasing barriers to the growth and advancement of the profession. The survey results show which areas need further development to lead us towards this goal. A good starting point is to ensure that RRAs are recognized nationally as advanced practitioners, consistent with their education, training, and scope of practice. A future survey could be geared toward radiologists to assess their understanding of what an RRA is, how they can assist, and what they feel comfortable entrusting to an RRA to complete. Such research may help identify educational gaps and misconceptions regarding the RRA role that influence utilization in clinical practice. Future SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 52 studies should also examine the perspectives of healthcare administrators and policymakers to better understand organizational and legislative barriers that affect RRA employment and practice authority. Legislative action is also needed to expand reimbursement opportunities for RRAs and to support practice capabilities comparable to those of other advanced practice healthcare professionals. Additional research evaluating the impact of RRAs on patient outcomes, workflow efficiency, healthcare costs, and patient satisfaction could provide evidence supporting broader implementation of the profession. Without broader recognition and institutional support, employers may continue to justify not hiring RRAs. RRAs also need to be treated equally by all healthcare practitioners, healthcare organizations, and policymakers to support consistent utilization of their skills and promote continued advancement of the profession. Continued advocacy, research, and collaboration among professional organizations will be essential to advancing the profession and ensuring that RRAs are utilized to the full extent of their education and clinical expertise. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 53 References American College of Radiology. (2022). ACR–ASRT practice standards for the radiologist assistant. ACR Publications. American College of Radiology. (2022). Radiologist assistant practice guidelines and technical standards. https://www.acr.org/Clinical-Resources/Radiologist-Assistant American College of Radiology Bulletin. (2024). 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SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES Appendix A Survey Questions (as entered in Qualtrics) SECTION 1: BACKGROUND INFORMATION What is your job title? ● Radiologist Assistant (RA) ● Radiology Practitioner Assistant (RPA) ● Registered Radiologist Assistant (RRA) Are you currently employed under that title? ● Yes ● No If you answered "no", please enter your current job title: ● ____ What state do you currently practice in? ● ___(will be drop down menu for answer) Have you practiced in or been licensed in more than one state? ● Yes ● No If you marked "yes", please specify which state(s): ● — How many years of experience do you have as an RA/RPA/RRA? ● 0-5 years ● 5-10 years ● More than 10 years 60 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES What is your age? ● 20-30 years ● 31-40 years ● 41-50 years ● 51-60 years ● 61+ years ● Prefer not to answer What is your primary practice setting? ● Hospital ● Outpatient Imaging Center ● Academic Medical Center ● Private Radiology group ● Other (please state below) ● ____ What is your salary range? ● <50,000 ● 50,000-70,000 ● 71,000-90,000 ● 91,000-120,000 ● 121,000+ ● Prefer not to say SECTION 2: SCOPE OF PRACTICE In your practice setting, what level of supervision does the radiologist perform? 61 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES ● Direct (Physician is immediately available) ● Indirect (Physician is available for verbal consultation) ● General (Physician is within the building) ● Personal (Physician is in the procedure with you) What clinical tasks/procedures are you currently allowed to perform in your role? (Please select all that apply) ● Gastrointestinal/Chest Procedures ● Genitourinary Procedures ● Invasive Nonvascular Procedures ● Invasive Vascular Procedures ● Pre procedure work-up / patient assessment (consenting, lab orders, exam appropriateness etc) ● Post procedure patient follow-up (suturing, monitoring vitals, post procedure care etc) ● Drafting preliminary readings/reports for radiologist review ● Other procedures not listed (please list below) ● _____ Please explain why you are restricted from performing any of the tasks listed above (select all that apply) ● State regulations ● Employer policy ● Liability concerns ● Radiologist preference 62 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES ● Lack of reimbursement/insurance restrictions ● Other ● N/A If you selected "other", please explain other limitations that restrict you from performing these tasks: ● SECTION 3: JOB SATISFACTION How satisfied are you with your current role as an RA/RPA/RRA? ● 1--Not satisfied at all ● 2--Dissatisfied ● 3--Neutral ● 4--Satisfied ● 5--Very Satisfied ● Prefer not to say What are the top 2-3 challenges you face in your role? ● How satisfied are you with your level of professional autonomy in performing procedure and patient care responsibilities? ● 1--Not satisfied at all ● 2--Dissatisfied ● 3--Neutral ● 4--Satisfied ● 5--Very Satisfied 63 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES ● Prefer not to say How satisfied are you with your compensation? ● 1--Not satisfied at all ● 2--Dissatisfied ● 3--Neutral ● 4--Satisfied ● 5--Very Satisfied ● Prefer not to say Would you recommend the RA/RPA/RRA profession to others? ● Yes ● No ● Prefer not to say Any additional comments about your role or how it could be improved? 64 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 65 Appendix B Consent Form IRB STUDY # IRB-AY25-26-158 INFORMED CONSENT Scope of Practice Variation Across the United States: Barriers to Standardization, Differences, and Policies That Affect Registered Radiologist Assistants (RRA) Utilization You are invited to participate in a web-based survey. This survey is part of a research project being conducted by graduate students in the Radiologic Sciences Department at Weber State University. We ask that you read this form and ask any questions you may have before agreeing to participate in the study. STUDY PURPOSE The purpose of this study is to gather information regarding differences in the scope of practice, policies, and barriers to standardization for the Registered Radiologist Assistant profession. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate, you will be one of 30+ subjects who will be participating in this research. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will do the following things: Answering survey questions in the form of multiple-selection, write in, or short answers. RISKS OF TAKING PART IN THE STUDY: We do not anticipate any foreseeable risks involved in participating in this study other than those encountered in day-to-day life. OR SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 66 There is the risk that you may find some of the questions to be sensitive. OR There is the risk that some questions may cause emotional discomfort. OR Some of the survey questions ask about personal experiences and may be distressing to you as you think about your experiences. OR The possible risks or discomforts of the study are minimal. You may feel a little uncomfortable answering personal survey questions. BENEFITS OF TAKING PART IN THE STUDY You will receive no direct benefits from participating in this research study. However, your responses will help us gain insight into the utilization of Registered Radiology Assistants. We hope that the information gathered in this study will be used to advocate for standardization in practice, improving training experience, job satisfaction, utilization, and advancement of the profession. ALTERNATIVES TO TAKING PART IN THE STUDY: Instead of being in the study, you have these options: Not taking part in the study COSTS/ COMPENSATION FOR INJURY There are no costs associated with participating in this survey. There will also be no compensation for participating in this survey. CONFIDENTIALITY Your survey answers will be sent to a link at Qualtrics.com, where data will be stored in a SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 67 password-protected electronic format. The survey will not collect identifying information such as your name, email address, or IP address. Therefore, your responses will remain anonymous. No one will be able to identify you or your answers, and no one will know whether or not you participated in the study. CONTACTS FOR QUESTIONS OR PROBLEMS If you have questions at any time about the study or procedures, you may contact our research supervisor, Dr. Ward, via email at taylorward2@weber.edu. If you feel you have not been treated according to the descriptions in this form, or that your rights as a participant in research have not been honored during this project, or if you have any questions, concerns, or complaints that you wish to address to someone other than the investigators, you may contact the Weber State Radiologic Science Department at Marriott Health Sciences Building 363 3891 Stadium Way Dept 3925, Ogden UT 84408-3925 VOLUNTARY NATURE OF STUDY Your participation in this survey is completely voluntary. You are free to decline to answer any particular question you do not wish to answer for any reason. You are free to withdraw consent and discontinue participation in the project at any time without penalty by closing the survey prior to completion. Any data collected prior to exiting the survey will still be recorded. SUBJECT’S ELECTRONIC CONSENT: Please select your choice below. You may print a copy of this consent form for your records. Clicking on the “I agree” button indicates that • You have read the above information SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES • You voluntarily agree to participate • You are 18 years of age or older ● I agree to participate ● I do not agree to participate 68 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES Appendix C ARRT R.R.A Form CR-1 69 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES Appendix C cont. ARRT R.R.A Form CR-1 70 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 71 Appendix D Email Recruitment Letter Dear Educator, You are invited to participate in this research project titled: “Scope of Practice Variation Across the United States: Barriers to Standardization, Differences, and Policies That Affect Registered Radiologist Assistants (RRAs) Utilization”. This study aims to analyze how RRAs are utilized across the country. The ARRT has established guidelines for what procedures an RRA can perform. However, different states have the ability to set boundaries within the scope of practice and hospitals, and private groups can further restrict what procedures are allowed. Further clarification is warranted that this study will neither establish or eliminate any standards or regulations that govern RRAs currently. This study is intended to help bridge the educational gap between the utilization of RRAs and the broader network of healthcare providers. This study is being conducted by Weber State University students in the Master of Radiologic Sciences program, in partial fulfillment of the Master of Science in Radiologic Science (MSRS) degree at Weber State University under supervision of Dr. Taylor Ward, Ph.D. You were selected as a potential participant because you are registered radiologist assistant. Participation in this study is completely voluntary. There are no more than minimal risks associated with participation in this study. All data collected will be completely anonymous. If you choose to participate in this study, you will be asked to click the link or use the QR code (below) to the survey. The survey should take about 5 minutes of your time. https://weber.co1.qualtrics.com/jfe/form/SV_agZBC8NQC94vgb4 This second link will take you to a detailed information letter about the survey. SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 72 Electronic Information Letter https://docs.google.com/document/d/1qNx1xsx4z6UwCgVDPFDx9bXaQUcHmiiiWGwfbFHoq OQ/edit?usp=sharing Your full participation is encouraged, as the data gathered can be valuable in clarifying regional discrepancies and guiding future efforts towards uniform scope of practice. Your input is vital for the success of this research study. Because this research is completely voluntary, you may choose to withdraw from the survey at any time by exiting the survey without submitting it, or by closing the internet browser. There will be no repercussions for choosing to withdraw from the study and will not jeopardize your future relations with Weber State University, the Dumke College of Health Professions, or the School of Radiologic Sciences. Once the data is submitted, the data cannot be withdrawn as it will be unidentifiable. Data obtained through your participation may be used in the publication of a thesis for an educational requirement, published in a professional journal, and/or presented at a professional conference. If you have any questions or concerns regarding this study, please contact Jenna Rodriguez Email: Jennarodriguez@mail.weber.edu Dr. Taylor Ward Email: taylorward2@weber.edu The Weber State University Institutional Review Board has approved this document for use on IRB-AY25-26-158 . SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES Thank you in advance for your time and participation! MSRS Students, 2026 Weber State University School of Radiologic Sciences 73 SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 74 Appendix E Information Letter for Research Participation Study Title: Scope of Practice Variations Across the United States: Barriers to Standardization, Differences, and Policies That Affect Registered Radiologist Assistants (RRAs) Utilization. Principal Investigator: Dr. Taylor Ward, Associate Professor, Radiologic Sciences, Weber State University IRB Number: IRB-AY25-26-158 The purpose of this study is to evaluate the barriers to standardization, differences, and policies that affect Registered Radiologic Assistants' (RRA) utilization. You are invited to take part in this study because you are an RRA or Radiologist Practitioner Assistant (RPA). This study will help us better understand and systematically examine the barriers influencing the utilization of physician extenders across the United States and identify evidence-based strategies to optimize the integration and effective use of RRA / RPAs within the health care system. If you agree to participate, you will be asked a series of personal and professional questions. This survey will be hosted by a third-party website and kept confidential throughout the questionnaire. It will take approximately 20 minutes to complete the survey. The risks of participating in this study may include questions that cause emotional discomfort, some questions may ask about personal experiences and may be distressing to you as you think about your experiences. There are no costs for you, and you will not be paid to take part in this study. You will not be personally identified in any reports or publications that may result from this study. Any personal SCOPE OF PRACTICE VARIATION ACROSS THE UNITED STATES 75 information about you that is gathered during this study will remain confidential to the extent of the law. You can refuse to answer any questions asked or written on any forms. Your participation in this study is voluntary, and you may decide to remove or stop your participation at any time. If you have any questions about this project, please contact Dr. Taylor Ward at taylorward2@weber.edu (801)-626-6617 or Rebecca Mace at beccamace@mail.weber.edu (719)-487-5784. This research project has been reviewed by the Internal Review Board of Weber State University in Ogden, Utah, IRB-AY25-26-158 . For any questions about your rights as a research subject, please call WSU Chairman Matthew Dnoahue at irb@weber.edu