To study the impact of transthoracic echocardiogram (TTE) on the length of stay, hospital charges and decision on anticoagulation usage in ischemic stroke (IS) or transient ischemic attack (TIA) patients at the national level.

TTE is recommended to rule out cardiac sources of embolism in IS or TIA patients and its impact on length of stay (LOS), hospital charges, and the decision on anticoagulation usage is not well studied before.

TIA/IS patients with primary diagnosis were identified from Nationwide Inpatient Sample database for years 2006-2014 using ICD 9 codes.  We compared age, gender, medical co-morbidities, in-hospital complications, cardiac source of embolism, anticoagulation therapy usage, length of stay, hospital characteristics and hospital charges in TTE vs No TTE patients. A multivariate model was adjusted for age, gender, medical co-morbidities, in-hospital complications and cardiac source of embolism.

Of 4,291,127 patients with TIA/IS, 11.6% patients had TTE. TTE patients were younger 64.0(± 15.1) vs 69.2(± 14.5), had fewer medical co-morbidities, and higher rates of cardiac source of embolism (9.52% vs 1.51%). No difference in anticoagulation use (2.38% vs 2.49%, p = 0.0994) between the groups.  LOS was longer (4.96 ± 5.89 vs 4.00 ± 5.2 days) and hospital charges were higher at $39,647.90 ± $47,921.80 vs 30,542.10 ± 42,212.70 for TTE group. TTE group had longer LOS (OR: 1.78; CI: 1.71-1.85). TTE was more often performed in teaching and urban hospitals upto 59.2% and 93.5% respectively). There was a substantial regional variation in the performance of ECHO: Northeast 26.8%, Midwest 21.8%, South 38.4%, and West 12.9% respectively. No significant difference in yearly utilization of ECHO from 2006 to 2014.