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We determined whether RF predicted adverse hospital outcomes independently of its causative illnesses. In a retrospective observational study from the Geriatric Risk Assessment and Care Evaluation database, we included 1093 patients consecutively admitted to a geriatric hospital unit (2022\u20132024). Study outcomes included hospital death, length of hospital stay (LOS) and post-discharge institutionalization (discharge to nursing homes or other long-term facilities). RF was diagnosed according to admission peripheral oxygen saturation\u2009\u2264\u200991%, or oxygen therapy\/non-invasive ventilation during hospitalization, or specific diagnostic discharge codes. The predictive role of RF was investigated controlling for RF causative illnesses, frailty measured by the Multidimensional Prognostic Index (MPI), and C-reactive protein. The RF prevalence was 43%. Compared to controls, RF patients had higher hospital mortality (25.4% vs. 6.0%) and longer LOS, but comparable institutionalization rate. The fully adjusted odds ratio (OR) of RF for hospital mortality was 3.98 (95% Confidence Interval [CI] 2.53\u20136.28) and further increased after exclusion of 106 acute-on-chronic RF patients (4.71, CI 2.96\u20137.49). MPI, C-reactive protein, and sepsis emerged as additional significant predictors of mortality. RF also predicted longer LOS (F 6.78, p 0.009) in a linear regression model, along with age, MPI, pneumonia, pulmonary embolism, stroke, and sepsis. RF was highly prevalent and predicted hospital mortality and longer LOS <jats:italic>per se<\/jats:italic>, independently of its causative acute illnesses, frailty, and systemic inflammation. Older patients should be actively screened for RF during hospitalization.<\/jats:p>","DOI":"10.1007\/s11739-025-04074-3","type":"journal-article","created":{"date-parts":[[2025,8,24]],"date-time":"2025-08-24T03:11:12Z","timestamp":1756005072000},"page":"2131-2139","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Respiratory failure, underlying acute illnesses, and hospital outcomes: the S. 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