Measuring what matters, measuring well: a call to strengthen health-related quality of life patient-reported outcome measures in cardiovascular care.

This invited commentary refers to ‘Psychometric properties of health-related quality of life patient reported outcome measures for common cardiovascular conditions: a scoping review and COSMIN analysis’, by A. Bhatty et al., https://doi.org/10.1093/eurjcn/zvaf217. In an era of value-based healthcare, the outcomes that matter most to patients have become the primary indicators of quality. A truly patient-centered approach requires capturing these outcomes from the patient's own perspective, moving beyond clinical biomarkers alone.1 Within this paradigm, patient-reported outcome measures (PROMs) have emerged as essential tools for capturing the patient’s assessment of their health status, providing data directly reported by patients without clinician or third-party interpretation.2 The routine integration of PROMs into clinical practice can enhance patient-clinician communication, align care with patient priorities, and support shared decision-making.3 However, the value of PROMs ultimately depends on their measurement quality and the context in which they are used. The application of PROMs in clinical settings has been studied for decades. As early as the 1980s, Rand et al.4 demonstrated that providing physicians with feedback from the General Health Questionnaire (GHQ) doubled the rate of psychiatric diagnoses, suggesting that PROMs can improve the recognition of conditions such as depression. However, the authors also cautioned against the risk of over diagnosis, emphasizing that such data require judicious interpretation. This early insight underscores a persistent challenge, as the push to implement PROMs must be matched by a strong commitment to their measurement quality. This frames the importance of the recent review by Bhatty et al.5 Within this context, the scoping review by Bhatty et al.5 represents a significant and timely contribution. The burden of cardiovascular diseases (CVDs) persists, driven by more individuals reaching advanced age with significant cardiovascular impairments.6 Health-related quality of life (HRQoL), the patient’s subjective assessment of how disease and its treatment effect symptoms and functioning across physical, mental, and social domains,7 is commonly assessed using PROMs, yet many PROMs used in individuals with CVD have notable limitations.8 The work of Bhatty et al.5 systematically evaluates the psychometric properties of 38 HRQoL PROMs across common CVDs using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) framework. Their findings reveal a concerning landscape, with only 11 PROMs (29%) meeting all nine COSMIN criteria for robust psychometric properties. The majority (50%) were rated ‘B’, requiring further validation, and 21% were rated ‘C’, offering insufficient evidence for clinical use. The most common deficiencies were observed in cross-cultural validity/measurement invariance, measurement error, and responsiveness, where these properties are critical for detecting true change over time and ensuring equity across diverse patient populations. The primary strength of their review lies in its methodological rigor. By applying the COSMIN framework uniformly across a wide range of CVDs, it provides an unprecedented, standardized comparison on the PROM quality. However, the review exposes a fundamental tension between implementation pressures and measurement principles. Major societies such as the International Consortium for Health Outcomes Measurement (ICHOM) have advocated for increased PROM uptake to standardize outcome tracking and improve coronary artery disease care quality.9 Yet, Bhatty et al.5 demonstrate that many available instruments may not be fit-for-purpose. Using a PROM with poorly characterized measurement error can obscure true treatment effects in clinical trials and increase Type II errors. In a clinical setting, it can misguide clinical decisions for patients. As emphasized by Huemer et al.10 for a PROM to be clinically useful, it must be reliable (free from measurement errors), valid (accurately measure what it claims to measure), and generate quantifiable data. Furthermore, the widespread lack of cross-cultural validity is a critical concern. A PROM must measure the same construct uniformly across different ethnic, linguistic, and social groups. Without this, as discussed in the ‘universalist’ model by Herdman et al.11 scores from a poorly adapted questionnaire are not comparable, with the risks of exacerbating health disparities rather than alleviating them. The drive to ‘measure what matters’ is hollow if we do not also ‘measure well.’ The review by Bhatty et al.5 sends a clear message that the validation of a PROM is not a one-time event but a continuous process. It also highlights a path forward through modern psychometric methods like Item Response Theory (IRT), which were scarcely used in the evaluated PROMs, yet they hold immense potential. As Terluin et al.12 note, IRT can estimate meaningful interpretative thresholds for multi-item questionnaires, provided assumptions such as unidimensional and a normally distributed latent trait are met. Therefore, based on the critical findings of Bhatty et al.5 we propose several recommendations. First, we must focus validation efforts strategically. Rather than developing a plethora of new instruments, resources should be directed toward addressing the specific gaps identified, particularly cross-cultural validation/measurement invariance and establishing the minimum clinically important difference and responsiveness for ‘B’-rated PROMs. This targeted approach is more efficient and impactful than starting from scratch. Second, we must enhance methodological quality by encouraging journal editors and reviewers to require adherence to COSMIN guidelines and, where appropriate, the use of advanced methods such as IRT. Concurrently, we should expand psychometrics training for clinical researchers so they can critically appraise PROM studies and contribute to this field with the necessary expertise. Finally, PROM data should be interpreted as one vital piece of a larger clinical puzzle, integrated with objective biomarkers and functional measures to support a holistic view of patient outcomes, as emphasized by Kluzek et al.13 The work by Bhatty et al.5 is more than just a scoping review. It is a call for a more scientifically grounded and ethically responsible approach to patient-centered care. It is imperative to ensure that the scores we collect truly reflect our patients’ voices and guide us toward better, more equitable patient outcomes. Mei Sin Chong (Ph.D. (Conceptualization [equal]; Writing—original draft [lead]; Writing—review & editing [equal])), and Wenru Wang (Conceptualization [equal]; Writing—review & editing [equal]) No financial support was received for the submitted work. No data used in the preparation of the submitted work.