OBJECTIVES: Diabetic foot ulcers present a substantial clinical and economic burden to health systems globally. We analysed their burden in a 5-year longitudinal population health review. METHODS: A retrospective observational study of inpatient and outpatient data from a university tertiary hospital in Singapore. Data included baseline characteristics, clinical outcomes, resource use and costs. Descriptive statistics, Kaplan-Meier survival analysis and Cox-proportional hazards regression models were performed. RESULTS: 1,729 patients were treated for diabetic foot ulcers, with mean age 63.4 years and 64.4% males. 61.4% of patients were Chinese, 13.5% Malay and 18.4% Indian. 74.8% had underlying peripheral arterial disease (PAD) and 14.5% had peripheral neuropathy, with median HbA1c 9.9%. More than a third had toe(s) amputation, 16.9% transmetatarsal and 6.5% major amputations. The mean inpatient length of stay for ulcer-only, minor amputation and major amputation was 13.3, 20.5 and 59.6 days respectively. Mean cost per patient-year was USD$3,368 (ulcer-only), USD$10,468 (minor amputation) and USD$30,131 (major amputation). Minor amputation-free survival was 80.9% at 1-year and 56.9% at 5-years while major amputation-free survival was 97.4% at 1-year and 91.0% at 5-years. Independent predictors for all-cause mortality were age (Hazard Ratio [HR] 1.1, p<0.001), major amputation (HR 1.8, p<0.001), PAD (HR 1.4, p=0.015), ischaemic heart disease (IHD) (HR 10.8, p<0.001), previous stroke (HR 1.2, p=0.041) and end-stage renal failure (ESRF) (HR 1.4, p=0.002). Independent predictors for major amputation were age (HR 1.0, p=0.002), PAD (HR 27.9, p<0.001), IHD (HR 12.3, p=0.033) and ESRF (HR 1.9, p=0.002). For minor amputation, independent predictors were male (HR 1.3, p<0.001) and PAD (HR 7.4, p<0.001). CONCLUSIONS: Within our study cohort, there is a significant clinical and economic burden of diabetic foot ulcers. These patients have poor glycaemic control, hence resulting in high wounds per patient ratio with escalating healthcare costs corresponding to more proximal amputation levels.