CUOREMA: Immersive Bio & Behavioral Feedback and Digital Interventions for Cardiac Rehabilitation – Exploratory Analysis

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Abstract
Aims.: Long-term adherence to cardiac rehabilitation (CR) remains low despite its proven benefits for secondary prevention. We explore the usability and engagement patterns of CUOREMA, a personalized mobile-health system integrating self-monitoring, wearable data, virtual coaching, and reinforcement learning-enhanced adaptive interventions to support lifestyle change during and after outpatient CR. Methods.: In a six-month two-center observational study (N = 53, Switzerland and France), patients in outpatient CR used the CUOREMA app. Usability was assessed via validated and solution-specific questionnaires. Engagement patterns were identified using k-means clustering on weekly app usage. Clusters were compared by demographics and psychological themes of personal goals. Health-related questionnaires and the 6-minute walk test (6MWT) were collected at baseline and follow-up visits. Results.: Three engagement clusters (dropout, sporadic, consistent) were identified and sup-ported by matching patterns across app components and smartwatch wearing time. Clusters were not associated with demographic factors. Psychological themes of personal goals sug-gested that intrinsic motivation was more common among sustained users, while extrinsic motivation was more frequent among early dropouts. User experience was rated positively. One center showed significant 6MWT improvement, though the study was not powered for clinical outcomes. However, attrition was high: only 19% of participants used the app on more than 100 days, and questionnaire response rates declined from 55% at baseline to 13% at six months, and health-related drop-out can not be ruled out. Conclusion.: Engagement variability driven by motivational rather than demographic fac-tors is a central challenge in digital CR. Tailoring interventions to individual motivational profiles may improve adherence. Graphical

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