Physician assistants/associates in psychiatry: a workforce analysis.

BACKGROUND: Physician assistants/associates (PAs) provide services in diverse medical specialties globally, including psychiatry. While health professionals in psychiatry have been described for many years, little is known about PAs practicing in this discipline. METHODS: We describe US PAs practicing in psychiatry using robust national data from the National Commission on Certification of Physician Assistants (NCCPA). Analyses included descriptive and inferential statistics comparing PAs in psychiatry to PAs in all other medical and surgical specialties. RESULTS: The percentage of PAs practicing in psychiatry has increased from 1.1% (n = 630) in 2013 to 2.0% (n = 2 262) in 2021. PAs in psychiatry differed from PAs practicing in all other specialties in the following: they identified predominately as female (71.4% vs. 69.1%; p = 0.016), were more racially diverse (Asian [6.6% vs. 6.0%], Black/African American [5.5% vs. 3.4%], multi-race [2.8% vs. 2.1%], and other races [Native Hawaiian/Pacific Islander, American Indian/Alaska Native, or other; 3.7% vs. 3.6%]; p < 0.001), and resided in the South (43.8% vs. 34.1%; p < 0.001). PAs in psychiatry vs. all other specialties were more likely to work in office-based private practice settings (41.6% vs. 37.3%; p < 0.001) and nearly twice as likely to provide telemedicine services for their patients (62.7% vs. 32.9%; p < 0.001). While one-third (31.9%) of PAs in psychiatry experienced one or more burnout symptoms, and 8.1% considered changing their current position, the vast majority of PAs in psychiatry (86.0%) were satisfied with their position. CONCLUSIONS: Understanding the attributes of PAs in psychiatry is essential in medical labor supply and demand research. Our findings suggest that the number of PAs working in psychiatry is steadily increasing. These PAs were predominantly female, exhibited greater racial diversity, and were primarily located in the South and Midwest regions of the US. A striking difference was that PAs in psychiatry were almost twice as likely to provide telemedicine services for their patients. Although nearly a third of PAs in psychiatry acknowledged having one or more symptoms of burnout, few were considering changing their employment, and the vast majority reported high job satisfaction.

Providing care in underresourced areas: contribution of the physician assistant/associate workforce.

BACKGROUND: Prior studies suggest that physician assistants/associates (PAs) are more likely than physicians to work in underresourced areas. However, data characterizing the current PA workforce in health professional shortage areas (HPSAs) and medically underserved areas (MUAs) are lacking. METHODS: We analyzed the 2022 cross-sectional dataset from a comprehensive national database to examine the demographic and practice characteristics of PAs working in HPSAs/MUAs compared to those in other settings. Analyses included descriptive and bivariate statistics, along with multivariate logistic regression. RESULTS: Nearly 23% of PAs reported practicing in HPSAs/MUAs. Among PAs in HPSAs/MUAs, over a third (34.6%) work in primary care settings, 33.3% identify as men, 15.6% reside in rural/isolated areas, and 14.0% are from an underrepresented in medicine (URiM) background. Factors associated with higher odds of practicing in a HPSA/MUA included residing in rural/isolated settings, URiM background, and speaking a language other than English with patients. CONCLUSIONS: As the PA profession grows, knowledge of these attributes may help inform efforts to expand PA workforce contributions to address provider shortages.

Utilizing Nurse Practitioners and Physician Assistants in Academic Emergency Departments Does Not Reduce Residents' Exposure to More Complex Patients.

BACKGROUND: Whether integration of nurse practitioners (NPs) and physician assistants (PAs) into academic emergency departments (EDs) affects emergency medicine (EM) resident clinical learning opportunities is unclear. OBJECTIVE: We sought to compare EM resident exposure to more-complex patients, as well as patients undergoing Accreditation Council for Graduate Medical Education (ACGME)-required procedures, at nonpediatric academic EDs with lower, moderate, and higher levels of NP/PA utilization. METHODS: In this cross-sectional study of National Hospital Ambulatory Medical Care Survey (NHAMCS) data for 2016-2020, nonpediatric academic EDs were classified into the following three groups based on the percentage of patients seen by an NP or PA: lower (≤ 10%), moderate (10.1-30%), and higher (> 30%) NP/PA utilization. The proportion of EM resident-seen patients meeting previously established complex patient criteria was then determined for EDs at each level of NP/PA utilization. The proportion of EM resident-seen patients receiving certain ACGME-required procedures was also determined. Survey analytic procedures and weighting as recommended by NHAMCS were used to calculate and compare proportions using 95% CIs. RESULTS: The weighted 2016-2020 NHAMCS data sets represent 44,130,996 adult resident-seen patients presenting to nonpediatric academic EDs. The proportion of resident-seen patients meeting complex patient criteria did not significantly differ for lower (43.2%; 95% CI 30.6-56.8%), moderate (41.7%; 95% CI 33.0-50.9%), or higher (38.9%; 95% CI 29.3-49.4%) NP/PA utilization EDs. The proportion of patients undergoing an ACGME-required procedure also did not significantly differ across level of NP/PA utilization. CONCLUSIONS: Higher levels of NP/PA utilization in nonpediatric academic EDs do not appear to reduce EM resident exposure to more-complex patients or ACGME-required procedures.

The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study.

BACKGROUND: Many countries are looking for ways to increase nurse practitioner (NP) and physician assistant/associate (PA) deployment. Countries are seeking to tackle the pressing issues of increasing healthcare demand, healthcare costs, and medical doctor shortages. This article provides insights into the potential impact of various policy measures on NP/PA workforce development in the Netherlands. METHODS: We applied a multimethod approach study using three methods: 1) a review of government policies, 2) surveys on NP/PA workforce characteristics, and 3) surveys on intake in NP/PA training programs. RESULTS: Until 2012, the annual intake into NP and PA training programs was comparable to the number of subsidized training places. In 2012, a 131% increase in intake coincided with extending the legal scope of practice of NPs and PAs and substantially increasing subsidized NP/PA training places. However, in 2013, the intake of NP and PA trainees decreased by 23% and 24%, respectively. The intake decreased in hospitals, (nursing) home care, and mental healthcare, coinciding with fiscal austerity in these sectors. We found that other policies, such as legal acknowledgment, reimbursement, and funding platforms and research, do not consistently coincide with NP/PA training and employment trends. The ratios of NPs and PAs to medical doctors increased substantially in all healthcare sectors from 3.5 and 1.0 per 100 full-time equivalents in medical doctors in 2012 to 11.0 and 3.9 in 2022, respectively. For NPs, the ratios vary between 2.5 per 100 full-time equivalents in medical doctors in primary care and 41.9 in mental healthcare. PA-medical doctor ratios range from 1.6 per 100 full-time equivalents in medical doctors in primary care to 5.8 in hospital care. CONCLUSIONS: This study reveals that specific policies coincided with NP and PA workforce growth. Sudden and severe fiscal austerity coincided with declining NP/PA training intake. Furthermore, governmental training subsidies coincided and were likely associated with NP/PA workforce growth. Other policy measures did not consistently coincide with trends in intake in NP/PA training or employment. The role of extending the scope of practice remains to be determined. The skill mix is shifting toward an increasing share of medical care provided by NPs and PAs in all healthcare sectors.

The Scope of Practice for Primary Cardiovascular Disease Prevention Expanded to Advanced Practice Providers: What Does the Data Show?

PURPOSE OF REVIEW: The review aims to explore the available literature on the role of advance practice providers (APPs) in the primary prevention of cardiovascular diseases (CVD). RECENT FINDINGS: CVD are the major cause of death and disease with the growing burden of direct and indirect costs. Globally, one out of every three deaths is due to CVD. A total of 90% of CVD cases are due to modifiable risk factors which are preventable; however, challenges are faced by the already overburdened healthcare systems where the shortage of workforce is a common constraint. Different CVD preventive programs are working but, in a silo, and with different approaches except in few of the high-income countries where specialized workforce such as advance practice providers (APPs) is trained and employed in practice. Such initiatives are already proven more effective in terms of health and economic outcomes. Through an extensive literature search of APPs' role in the primary prevention of CVD, we identified very few high-income countries where APPs' role has already been integrated into the primary healthcare system. However, in low- and middle-income countries (LMICs), no such roles are defined. In these countries, either the overburdened physicians or any other health professionals (not trained in primary prevention of CVD) sometimes provide brief advice on CVD risk factors. Hence, prompt attention is appealed by the current scenario of CVD prevention specifically in LMICs.

How does government policy influence the employment and training of nurse practitioners and physician assistants? A realist analysis using qualitative interviews.

AIMS: The aim of this study was to develop insights into how and why Dutch government policies on deployment and training of nurse practitioners and physician assistants have effect and under what circumstances. DESIGN: A realist analysis using qualitative interviews. METHODS: Data analysis of 50 semi-structured interviews conducted in 2019 with healthcare providers, sectoral and professional associations, and training coordinators. Stratified purposive and snowball sampling were used. RESULTS: Policies stimulated employment and training of nurse practitioners and physician assistants by: (1) contributing to the familiarity of participants in the decision-making process in healthcare providers with and medical doctors' trust in these professions; (2) contributing to participants' motivation in employment and training; and (3) eliminating barriers perceived by medical doctors, managers and directors. The extent to which policies affected employment and training was largely determined by sectoral and organizational circumstances, such as healthcare demand and complexity, and decision-makers in healthcare providers (medical doctors or managers/directors). CONCLUSION: Effectuating familiarity and trust among participants in the decision-making process is a crucial first step. Next, policymakers can motivate participants and lower their perceived barriers by extending the scope of practice, creating reimbursement opportunities and contributing to training costs. Theoretical insights into nurse practitioner and physician assistant employment and training have been refined. IMPACT: The findings highlight how governments, health insurers, sectoral and professional associations, departments, councils, healthcare providers and professionals can facilitate and support nurse practitioner and physician assistant employment and training by contributing to familiarity, trust and motivation, and by clearing perceived barriers.

The association of physician assistant/associate demographic and practice characteristics with perceptions of value of certification.

BACKGROUND: To determine physician assistant/associate (PA) perceptions of the value of certification and explore how they vary across demographic and practice characteristics. METHODS: We conducted a cross-sectional online survey between March and April 2020 with PAs participating in the longitudinal pilot program for recertification administered by the National Commission on Certification of Physician Assistants (NCCPA). The survey was distributed to 18,147 PAs, of which 10,965 participated (60.4% response rate). In addition to descriptive statistics, chi-square tests were conducted on demographics and specialty to examine if perceptions of value of certification (1 global and 10 items measuring specific domains) were associated with a particular PA profile. A series of fully adjusted multivariate logistic regressions were performed, exploring the relationship between PA characteristics and the value of certification items. RESULTS: Most PAs strongly agreed/agreed that certification helps with fulfilling licensure requirements (9,578/10,893; 87.9%), helps with updating medical knowledge (9,372/10,897; 86.0%), and provides objective evidence of continued competence (8,875/10,902; 81.4%). The items receiving the lowest percentage of responses for strongly agreeing/agreeing were for certification providing no value (1,925/10,887; 17.7%), helping with professional liability insurance (5,076/10,889; 46.6%), and competing with other providers for clinical positions (5,661/10,905; 51.9%). Age 55 and older and practicing in dermatology and psychiatry were among the strongest predictors of less favorable views. PAs from underrepresented in medicine (URiM) backgrounds had more positive perceptions. CONCLUSIONS: Overall, the findings indicate that PAs value certification; however, perceptions varied by demographics and specialties. PAs who were younger, from URiM backgrounds, and practicing in primary care specialties had among the most favorable perspectives. Continued feedback monitoring is critical in ensuring certification is relevant and meaningful in supporting PAs across demographics and specialties. Measuring PA perceptions of the value of certification is essential to understanding how to support the PA profession's current and future credentialing needs and those who license and hire PAs.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia.

INTRODUCTION: Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD. METHODS: Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month. RESULTS: For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates. DISCUSSION: APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD. HIGHLIGHTS: For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

Developing and evaluating an instrument to assess perceptions of an entry-level physician associate doctoral degree.

BACKGROUND: Most health professions in the United States have adopted clinical or practice doctorates, sparking an ongoing debate on whether physician assistants/associates (PAs) should transition from a master's to a doctorate as the terminal degree for the profession. Although more studies are anticipated, there is no validated instrument assessing perceptions of various stakeholders regarding an entry-level PA doctoral degree. The objective of this study was to develop and evaluate a novel self-report measure to assess perceptions of an entry-level PA doctoral degree. METHODS: A multifaceted, mixed-methods approach was adopted. Based on a comprehensive literature review of the doctoral transition experiences in other health professions, an initial version of perceptions of an entry-level terminal PA doctoral degree scale (PEDDS) was generated. This scale was pilot tested with a group of PA faculty, students, and clinicians. Then, a cross-sectional survey consisting of 67 items was conducted with a national random sample of practicing PAs and PA students. Additionally, semi-structured interviews were conducted to ensure the validity of PEDDS. A principal component analysis (PCA) was conducted to reduce the number of items and reveal the underlying structure of PEDDS. RESULTS: The PCA confirmed 10 factors of PEDDS consisting of 53 items as the best-fit factor structure with adequate internal consistency of subscales. Those factors include a) expected positive impact on the PA profession, b) expected impact on prerequisites, (c) expected impact on the student preparedness as PA faculty and educators, (d) expected impact on the student preparedness as clinicians, (e) expected impact on accreditation and certification, (f) expected impact on curriculum, (g) expected impact on PA educators, (h) expected positive impact on diversity, (i) expected negative impact on the PA profession, and (j) expected impact on the student competency. CONCLUSIONS: The present study highlights the need to develop valid and reliable measurements to assess perceptions regarding the transition to the entry-level doctorate across health professions. This study could be used to guide further discussion of the entry-level doctorates for PAs and other health professions by bridging the gap of existing literature related to valid, reliable, and standardized measures on this topic.

An assessment of physician assistant student diversity in the United States: a snapshot for the healthcare workforce.

BACKGROUND: The Physician Assistant (PA) workforce falls short of mirroring national demographics mainly due to a lack of diversity in student enrollment. Few studies have systematically examined diversity across PA programs at the national level, and little is known about best practices for consistently graduating a diverse group of students. We descriptively characterized the extent to which PA programs are graduating a diverse group of students and identified top performing PA programs. METHODS: Data from the Integrated Postsecondary Education Data System (IPEDS) were used to calculate the number and proportion of racial or ethnically diverse graduates. The study sample included 139 accredited PA programs that had graduated a minimum of five cohorts from 2014-2018. Within each of the United States Census Divisions, programs were ranked according to the number and proportion of graduates who were underrepresented minority (URM) race, Hispanic ethnicity, and of non-white (URM race, Hispanic, and Asian). RESULTS: Amongst PA programs in the United States, a large disparity in the number and proportion of racial and ethnic graduates was observed. Of 34,625 PA graduates, only 2,207 (6.4%) were Hispanic ethnicity and 1,220 (3.5%) were URM race. Furthermore, a large number of diverse graduates came from a small number of top performing programs. CONCLUSION: Despite the abundance of evidence for the need to diversify the healthcare workforce, PA programs have had difficulty recruiting and graduating a diverse group of students. This study provides empirical evidence that PA programs have not been able to attain the level of diversity necessary to shift the lack of diversity in the PA workforce. Based upon this study's findings, the top performing PA programs can be used as role models to establish benchmarks for other programs. The results of this descriptive study are currently being used to guide a qualitative study to identify the top performers' strategies for success.

The application of the constructivism learning theory to physician assistant students in primary care.

When examining different clinical programs, educators must incorporate the most appropriate educational theory to the learners, especially in a clinical setting. The implementation of constructivism learning theory will help preceptors and learners understand and assess educational content appropriately. This literature review covers the key components on the application of constructivism learning theory to physician assistant students in primary care. The history, fundamental principles, and the clinician/educator role in constructivism learning theory are discussed.

The Mental Status Exam at the Movies: The Use of Film in a Behavioral Medicine Course for Physician Assistants.

OBJECTIVE: This study evaluated student satisfaction with an educational exercise using feature films to learn about performing a psychiatric mental status examination. METHODS: Following the completion of an educational exercise designed by the first author, students in a behavioral medicine course completed surveys regarding their satisfaction with the exercise as a tool for learning how to perform a mental status examination. The educational exercise involved an initial didactic lecture followed by group exercises and individual presentations, utilizing feature films as tools for understanding the mental status examination. Each student selected a movie depicting a character with a psychiatric or substance-use disorder and performed a hypothetical mental status examination for the character, which they presented to their classmates. RESULTS: One hundred nine (109) students (97.3%) in the course completed evaluations of the educational exercise, and the majority found the exercise valuable; 93.6% of respondents felt that their ability to conceptualize a case had improved because of the exercise. In general evaluations of the course, this particular educational exercise was frequently mentioned in response to a free-form question about "the best part of the course." CONCLUSION: Movies depicting psychiatric illness and substance use disorders can be a fun and highly effective tool for helping students to learn and develop competency in the performance of mental status examinations.

Introducing physician associates to hospital patients: Development and feasibility testing of a patient experience-based intervention.

BACKGROUND: Physician associates (PAs) are one of many new mid-level health practitioner roles being introduced worldwide. They are a recent innovation in English hospitals. Patient confusion with novel mid-level practitioner titles and roles is well documented, alongside evidence of a positive association between patients' ability to identify practitioners and patient satisfaction. No prior research developed an intervention to introduce PAs or any other new practitioner role to hospital patients. OBJECTIVE: To develop, with patient and public involvement and engagement (PPIE), an intervention for introducing the PA role to hospital patients, and to test feasibility. METHODS: Intervention development was underpinned by an experience-based co-design approach. Workshop participants generated ideas for introducing PAs, subsequently explored in semi-structured interviews with hospital patients (n = 13). Interview findings were used by participants in a second workshop to design the intervention. Feasibility of the intervention was assessed in relation to its acceptability and efficacy using semi-structured interviews with hospital patients (n = 20) and PAs (n = 3). RESULTS: The intervention developed was a patient information leaflet. It was considered feasible to use in the hospital setting, helpful to patients in understanding the PA role and acceptable to both patients and PAs. The intervention was also appreciated by patients for providing reassurance of care and support. CONCLUSIONS: An experience-based co-design approach enabled development of an intervention tailored to patients' experiential preferences. Positive evidence of feasibility and utility is encouraging, supporting future larger-scale testing. PATIENT AND PUBLIC CONTRIBUTION: PPIE representatives were involved in the study design, intervention development and data interpretation.

Physician associate/assistant contributions to cancer diagnosis in primary care: a rapid systematic review.

BACKGROUND: Symptom recognition and timely referral in primary care are crucial for the early diagnosis of cancer. Physician assistants or associates (PAs) have been introduced in 18 healthcare systems across the world, with numbers increasing in some cases to address primary care physician shortages. Little is known about their impact on suspected cancer recognition and referral. This review sought to summarise findings from observational studies conducted in high income countries on PAs' competence and performance on processes concerned with the quality of recognition and referral of suspected cancer in primary care. METHOD: A rapid systematic review of international peer-reviewed literature was performed. Searches were undertaken on OVID, EMBASE, Web of Science, and CINAHL databases (2009-2019). Studies were eligible if they reported on PA skills, processes and outcomes relevant to suspected cancer recognition and referral. Title and abstract screening was followed by full paper review and data extraction. Synthesis of qualitative and quantitative findings was undertaken on three themes: deployment, competence, and performance. Preliminary findings were discussed with an expert advisory group to inform interpretation. RESULTS: From 883 references, 15 eligible papers were identified, of which 13 were from the USA. Seven studies reported on general clinical processes in primary care that would support cancer diagnosis, most commonly ordering of diagnostic tests (n = 6) and referrals to specialists (n = 4). Fewer papers reported on consultation processes, such as examinations or history taking (n = 3) Six papers considered PAs' competence and performance on cancer screening. PAs performed similarly to primary care physicians on rates of diagnostic tests ordered, referrals and patient outcomes (satisfaction, malpractice, emergency visits). No studies reported on the timeliness of cancer diagnosis. CONCLUSION: This review of peer-reviewed literature combined with advisory group interpretation suggests the introduction of PAs into primary care may maintain the quality of referrals and diagnostic tests needed to support cancer diagnosis. It also highlights the lack of research on several aspects of PAs' roles, including outcomes of the diagnostic process.

Exploring burnout and job stressors among advanced practice providers.

BACKGROUND: Minimal research exists on how engagement, burnout, work-family balance, and job stressors impact advanced practice nurses and physician assistants, collectively referred to advanced practice providers (APPs). PURPOSE: To investigate the interrelationships among burnout, job stressors, work-family balance, and engagement with APPs. METHODS: An online questionnaire was distributed to APPs working in four healthcare systems. A total of 1,216 APPs completed the survey. A hypothesized model was tested using structural equation modeling. FINDINGS: There was a high correlation of job stressors with development of burnout. A significant negative effect between job stress and work engagement was supported; however, indirect effects of stress through job burnout had a stronger impact on work engagement. Higher levels of work-family balance contributed to a lower level of stress experienced by providers. DISCUSSION: Organizational leaders desiring to improve employee engagement and reduce burnout need to focus on the significance of work-family balance to job stressors.

Primary Care Appointments for Medicaid Beneficiaries With Advanced Practitioners.

Primary care access in Medicaid improved after the Patient Protection and Affordable Care Act despite millions of new beneficiaries. One possible explanation is that practices are scheduling more appointments with advanced practitioners. To test this theory, we used data from a secret shopper study in which callers simulated new Medicaid patients and requested appointments with 3,742 randomly selected primary care practices in 10 states. Conditional on scheduling an appointment, simulated patients asked whether the practitioner was a physician or advanced practitioner. From 2012 through 2016, the proportion of appointments scheduled with advanced practitioners increased from 7.7% to 12.9% (P <.001) across the 10 states.

Diagnostic Imaging Examinations Interpreted by Nurse Practitioners and Physician Assistants: A National and State-Level Medicare Claims Analysis.

OBJECTIVE. Nonphysician providers (NPPs) increasingly perform imaging-guided procedures, but their roles interpreting imaging have received little attention. We characterize diagnostic imaging services rendered by NPPs (i.e., nurse practitioners and physician assistants) in the Medicare population. MATERIALS AND METHODS. Using 1994-2015 Medicare Physician/Supplier Procedure Summary Master Files, we identified all diagnostic imaging services, including those billed by NPPs, and categorized these by modality and body region. Using 2004-2015 Medicare Part B 5% Research Identifiable File Carrier Files, we separately assessed state-level variation in imaging services rendered by NPPs. Total and relative utilization rates were calculated annually. RESULTS. Between 1994 and 2015 nationally, diagnostic imaging services increased from 339,168 to 420,172 per 100,000 Medicare beneficiaries (an increase of 24%). During this same period, diagnostic imaging services rendered by NPPs increased 14,711% (from 36 to 5332 per 100,000 beneficiaries) but still represented only 0.01% and 1.27% of all imaging in 1994 and 2015, respectively. Across all years, radiography and fluoroscopy constituted most of the NPP-billed imaging services and remained constant over time (e.g., 94% of all services billed in 1994 and 2015), representing only 0.01% and 2.1% of all Medicare radiography and fluoroscopy services. However, absolute annual service counts for NPP-billed radiography and fluoroscopy services increased from 10,899 to 1,665,929 services between 1994 and 2015. NPP-billed imaging was most common in South Dakota (7987 services per 100,000 beneficiaries) and Alaska (6842 services per 100,000 beneficiaries) and was least common in Hawaii (231 services per 100,000 beneficiaries) and Pennsylvania (478 services per 100,000 beneficiaries). CONCLUSION. Despite increasing roles of NPPs in health care across the United States, NPPs still rarely interpret diagnostic imaging studies. When they do, it is overwhelmingly radiography and fluoroscopy. Considerable state-to-state variation exists and may relate to local care patterns and scope-of-practice laws.