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• Women have different lived experiences with heart failure, and different experiences could influence patients' interpretations of patient-reported outcome (PRO) items. • A presumption in the use of PRO measures is that patients interpret PRO questions similarly, regardless of their race, ethnicity, gender, etc. • When 2 groups of patients (eg, men and women, older and younger patients, various racial groups) interpret and respond to a PRO item differently for reasons other than the outcome of interest, differential item functioning (DIF) is present. • Without formally testing for DIF, it is possible that conclusions drawn from studies using PRO measures are biased, either by revealing subgroup differences that do not actually exist or by masking subgroup differences that really do exist. • As we strive toward equity in health outcomes, it is important that the tools we use to measure outcomes are not biased, and DIF evaluations provide a tool for examining our patient-reported outcome measures in heart failure and beyond. 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. [ABSTRACT FROM AUTHOR]