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We aimed to estimate the independent effect of pre-hospital frailty (PHF) on hospital mortality and prolonged hospital length of stay (pLOS) while adjusting for other patient level factors.This is a cohort study of hospitalized adults with acute respiratory failure (ARF) who required invasive mechanical ventilation for ≥24 h in 2013. We used inpatient/outpatient claims from a list of diagnoses from the year before index hospital admission to define PHF. Differences in characteristics/outcomes by PHF were explored using descriptive statistics; multivariable logistic regression was used to estimate association between PHF and hospital outcomes.Among 1157 patients (mean age (standard deviation) 67.1 [16.4]), 53.2% had PHF. PHF was independently associated with higher hospital mortality (44.2% in PHF patients vs. 34.6% in those without, adjusted Odds Ratio (aOR) (95% Confidence Interval [CI] 1.56 (1.19–2.05), p < 0.001). PHF was also significantly associated with pLOS in hospital survivors (55.5% PHF patients had pLOS versus 34.2% in those without, aOR (95% CI) 2.61 (1.87–3.65), p < 0.001).PHF, identified by frailty diagnoses from before index hospitalization, may be a useful approach for identifying adults with ARF at increased risk of hospital mortality and pLOS.Acute respiratory failure is the most common acute organ dysfunction in US hospitals, associated with a high risk of morbidity and mortality.Pre-hospital frailty, a syndrome of age or disease-related decline in physiologic reserve, has been associated with adverse outcomes in acutely ill elderly adults but has not been explored in adults with acute respiratory failure.In a cohort of 1157 adults with acute respiratory failure, we found that about 53% had diagnoses in the year prior to the index hospitalization consistent with pre-hospital frailty.Pre-hospital frailty was associated with 1.5x the odds of dying in the hospital and more than 2.5x the odds of surviving after a prolonged hospital length-of-stay.Our findings suggest that health systems may be able to use a diagnosis-based approach to systematically risk stratify patients with acute respiratory failure.