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Women diagnosed with heart failure report worse quality of life than men on patient-reported outcome (PRO) measures. An inherent assumption of PRO measures in heart failure is that women and men interpret questions about quality of life the same way. If this is not the case, the risk then becomes that the PRO scores cannot be used for valid comparison or to combine outcomes by subgroups of the population. Inability to compare subgroups validly is a broad issue and has implications for clinical trials, and it also has specific and important implications for identifying and beginning to address health inequities. We describe this threat to validity (the psychometric term is differential item functioning), why it is so important in heart-failure outcomes, the research that has been conducted thus far in this area, the gaps that remain, and what we can do to avoid this threat to validity. PROs bring unique information to clinical decision making, and the validity of PRO measures is key to interpreting differences in heart failure outcomes., Competing Interests: Disclosures JS owns the copyright to the KCCQ and receives license fees for the KCCQ. JS receives consulting fees from Bayer, Merck, Novartis, BMS, Janssen, and United Healthcare. JS is supported in grants from Abbott Vascular, Janssen and Myokardia and is on the Board of Directors for Blue Cross Blue Shield of Kansas City. RM received research support and honoraria from Abbott, American Regent, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim/Eli Lilly, Boston Scientific, Cytokinetics, Fast BioMedical, Gilead, Innolife, Medtronic, Merck, Novartis, Relypsa, Respicardia, Roche, Sanofi, Vifor, and Windtree Therapeutics. TC received research support from Merck and has a consulting agreement with Regenxbio. LL, KW, BR, IP, FB, MT, AS, DH, and BC have no competing interests to disclose., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)